1. Enter your contact hours for each client in the worksheets labled C (1) through C (10). Hours must be in decimal notation. If you are not sure on how to convert minutes to a decimal notation use the "min-decimal converter" worksheet. 2. Hour sheets must not be saved on lab computers. 3. Make sure that you backup your work. You will be updating the workbook each semester. 4. After updating the worksheets, print off a copy of the summary and all worksheets that require a supervisor's signature. If the sheet takes up more than one printed page go to the Page Setup Menu and change the scaling to "Fit to: 1 page tall and 1 page wide" 5. Be sure to turn in signed copies of your hours worksheets and summary to the clinic supervisor. 6. You may change to name of the worksheets by double clicking on the tab at the bottom of the sheet and typing in a new name. For example, you can change C (1) to read Spring 04 - <supervisor's name> Use this Worksheet to convert minutes to a decimal notation. decimal decimal minutes equivalent minutes equivalent 60 1.00 30 0.50 59 0.98 29 0.48 58 0.97 28 0.47 57 0.95 27 0.45 56 0.93 26 0.43 55 0.92 25 0.42 54 0.90 24 0.40 53 0.88 23 0.38 52 0.87 22 0.37 51 0.85 21 0.35 50 0.83 20 0.33 49 0.82 19 0.32 48 0.80 18 0.30 47 0.78 17 0.28 46 0.77 16 0.27 45 0.75 15 0.25 44 0.73 14 0.23 43 0.72 13 0.22 42 0.70 12 0.20 41 0.68 11 0.18 40 0.67 10 0.17 39 0.65 9 0.15 38 0.63 8 0.13 37 0.62 7 0.12 36 0.60 6 0.10 35 0.58 5 0.08 34 0.57 4 0.07 33 0.55 3 0.05 32 0.53 2 0.03 31 0.52 1 0.02 ASHA HOUR FORM - SUMMARY - UW WHITEWATER STUDENT NAME: Allison Zimmerman SEMESTER/YEAR: Fall/2013 On-Campus Off-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 2.163 1 0 0 0 2.333 0.83 3.163 intervention 4.5 12 10.583 0 0 4.5 5.583 21.5 27.083 Fluency evaluation 0 0 0 0 0 0 0 0 0 intervention 0 0 0 0 0 0 0 0 0 Voice and evaluation 0 0 0 0 0 0 0 0 0 Resonance intervention 0 0 0 0 0 0 0 0 0 Receptive and Speaking/Listening Expressive evaluation 0 1.5 0 0 0 0 1.5 0 1.5 Language intervention 0 2.5 0 0 0 0 0 2.5 2.5 Writing/Reading evaluation 0 0.166 0 0 0 0 0.166 0 0.166 intervention 0 0 2.75 0 0 0 0 2.75 2.75 Manual evaluation 0 0 0 0 0 0 0 0 0 intervention 0 0 0 0 0 0 0 0 0 Hearing evaluation 0 5.67 0 0 0 0 2 3.67 5.67 intervention 0 0 0 0 0 0 0 0 0 Swallowing evaluation 0 0 0 0 0 0 0 0 0 intervention 0 0 0 0 0 0 0 0 0 Cognitive Aspects evaluation 0 0 0 0 0 0 0 0 0 of Communication intervention 0 2.67 0 0 0 0 0 2.67 2.67 Social Aspects evaluation 0 0 0 0 0 0 0 0 0 of Communication intervention 0 0 0 0 0 0 0 0 0 AAC Assistive evaluation 0 0 0 0 0 0 0 0 0 Technology intervention 0 0 0 0 0 0 0 0 0 Summary of Hours by Age & CLD 4.5 26.669 14.333 0 0 4.5 11.582 33.92 Total Number of Hours 45.502 Student Signature __________________________________________________ Date: Clinic Coordinator __________________________________________________ Date: Signature ASHA Acount Number ______________________ (revised 5/15/2013/sb) ASHA HOUR FORM - UW WHITEWATER Student Name: Allison Zimmerman Practicum Setting: Williams Bay Elementary Semester/Year/ Supervisor Fall/2013/Dana Syring On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0.83 0.83 0.83 intervention 3 10.33 3 2.5 16.33 16.33 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 3.67 3.67 3.67 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 2.67 2.67 2.67 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 3 17.5 3 0 0 2.5 0 23.5 Total Number of Hours 23.5 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Allison Zimmerman Practicum Setting: Washington Elementary School Semester/Year/ Supervisor Fall/2013/Melanie Lindstrum On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 1.5 1.67 2 2 5.17 5.17 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 2.5 2.5 2.5 Writing/Reading evaluation 0 intervention 2.75 2.75 2.75 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 1.5 4.17 4.75 0 0 2 0 10.42 Total Number of Hours 10.42 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Allison Zimmerman Practicum Setting: UWW-CCD Semester/Year/ Supervisor Fall/2013/Beth Miller Swanson On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 1.333 1 2.333 2.333 intervention 5.583 5.583 5.583 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 1.5 1.5 1.5 Language intervention 0 Writing/Reading evaluation 0.166 0.166 0.166 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 2 2 2 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 4.999 6.583 0 0 0 11.582 0 Total Number of Hours 11.582 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________ ASHA HOUR FORM - UW WHITEWATER Student Name: Practicum Setting: Semester/Year/ Supervisor On-CampusOff-Campus Total Hours Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category *Hours noted in the Culturally/Linguistically Diverse (CLD) category are not included in the total number of hours Articulation evaluation 0 intervention 0 Fluency evaluation 0 intervention 0 Voice and evaluation 0 Resonance intervention 0 Receptive and Speaking/Listening Expressive evaluation 0 Language intervention 0 Writing/Reading evaluation 0 intervention 0 Manual evaluation 0 intervention 0 Hearing evaluation 0 intervention 0 Swallowing evaluation 0 intervention 0 Cognitive Aspects evaluation 0 of Communication intervention 0 Social Aspects evaluation 0 of Communication intervention 0 AAC Assistive evaluation 0 Technology intervention 0 Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0 Total Number of Hours 0 Student Signature __________________________________________________ Date: ______________ Supervisor Signature __________________________________________________ Date: ______________ ASHA Certification: SLP A ASHA Account Number: _______________