Texas Department of Licensing and Regulation PO Box 12087 ¢ Austin, Texas 78711-2157 (800) 803-9202 « (512) 463-6599 « FAX (512) 475-2874 won tdi.texas.gov © cs.speech@tdlr.texas.gov CLINICAL OBSERVATION AND EXPERIENCE FORM FOR SPEECH-LANGUAGE PATHOLOGY ASSISTANT DO NOT WRITE ABOVE THIS CINE « TO BE COMPLETED BY COLLEGE/UNIVERSITY PROGRAM DIRECTOR OR APPROVED COLLEGE/UNIVERSITY DESIGNEE Rule §111.50(a)(3) requires the applicant for the assistant license to have earned no fewer than twenty-five (25) hours of clinical observation in the area of speech-language pathology and twenty-five (25) hours of diinical assisting experience in the area of speech-language pathology obtained within an educational institution or in one of its cooperating programs or under the direct supervision at their place of employment. 1. Name of Student eronth FRED APTHUP 2. Student Social Security #: ‘Gea ratacion Shea or man srenedcaienn UMIVePGNTY| NORD TexAS 4. Indicate below the number of hours eamed in spe juage pathology (Enter “0” if none accrued.) Note: All hours must be earned in the same professional area for which the applicant is applying Clinical Observation: 20.4 Number of clock hours earned Clinical Experience: Number of clock hours earned 5. Program Director or Director Designee GTACY NUNNELES MR. CCC-SLP Print Name PAC [2-N-1F Saas, Date 7 TOLR Form SPADIT October 2016University of North Texas ‘Speech and Hearing Center Observation Hours Name: Fisher, Fred Arthur Date: Fall 2019 0/3010 2.25 2.25 Total 30.38 0.28 30,66, Required 25 25 25 Remaining 5.38 2a72 | 5.66 “for SLP-A license, all 25 observation hours must be ‘completed in the same field (SLP of Aud) Aaaea by g. WAC Printed Name: Stacy Nunnetee MA. Cos_v¥ asanumber _) 104153 Date: 12-4