Get Slpcf Report And Rating Form

Filling out the Slpcf Report And Rating Form is an essential part of the speech-language pathology clinical fellowship process. This guide provides a clear, step-by-step approach to completing the form online, ensuring that you meet all required standards.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your name in Section 1, filling in all three name fields: last, first, and middle. If applicable, include your maiden or former name.
3. Provide your home address, including street, city, state, and zip code, and your home phone number in the specified field.
4. Enter your social security number accurately; follow the format indicated in the form.
5. Acknowledge your responsibility regarding your mentor's ASHA certification by signing and dating the form.
6. In Section 2, fill in your mentor's full name and ASHA account number, and ensure your mentor signs and dates their section.
7. Complete Section 3 by providing the facility name, phone number, and full address where the clinical fellowship took place.
8. Specify the duration of the SLPCF in Section 4 by entering the beginning and ending dates, along with the total number of weeks of the fellowship experience.
9. In Section 5, detail the hours worked per week in direct clinical contact, ensuring accurate reporting for each category, and total up these hours.
10. Use Section 6 to rate the clinical fellow's skills, circling the appropriate ratings for each skill as discussed with your mentor.
11. In Section 7, confirm the mentor's recommendations and verification of information by selecting 'yes' or 'no' as appropriate for each statement.
12. Finally, complete Section 8 with the signatures of both the mentor and clinical fellow, verifying the discussion of the report. Ensure it is signed after the completion of the fellowship experience.
13. Once all fields are completed and verified, save your changes, and choose whether to download, print, or share the filled form as needed.

Complete your Slpcf Report And Rating Form online today for timely processing of your certification application.