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APPENDIX O

UNIVERSIDAD DEL TURABO


SCHOOL OF HEALTH SCIENCES
SPEECH-LANGUAGE PATHOLOGY PROGRAM
CLINICAL OBSERVATION FORM - ASSESSMENT
STUDENT NAME
DATE
COURSE
DURATION: 1hr

45min

Other _____
SERVICE PROVIDED TO: adult

30min

20min

adolescent

children

infant
SELECT INTERVENTION TYPE: speech

15 min

STUDENT ID
SETTING
SLP NAME
SLP SIGNATURE AND ASHA #
SELECT INTERVENTION AREA : feeding
articulation

AAC

voice

fluency

aural rehabilitation

language

combined
Answer the following questions using narrative style. Use an additional sheet of paper if necessary. Hand this
Form to the clinician delivering the service. Have the clinician sign the form and providing the ASHA account
number.
1. How was the patients case history taken?

2. What case history questions were more meaningful to you? Explain

3. Do you think all questions asked during the case history were adequate and appropriate given the patient situation?
4. Observe while the clinician provides directions to the patient before and during the assessment process. Which part of the
process cought your attention? Did the instructions seam clear and appropriate to the client situation?

5. What strategies did the clinician use to make sure the patient understood the formal test instructions?

6. Name and describe the formal measures used during the evaluation.

7. Which informal (criterion referenced) activities were administered?

8. Which measures did the clinician took to safeguard the patient answers to avoid anxiety about his performance on the
test/procedure?

9.Observe what happens once the evaluation iscompleted. How does the clinician summarize the patients performance to
parents, family members or to the patient itself?

Prepared by:
Dr. Nydia Bou, Aug/2007, Rev May 2011, Rev. May/2014 Del Valle

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