Clinician:		Setting:		Date:
Supervisor:		Semester:		Suggested Grade:

This form is provided as a convenience, you may use it or provide a narrative or other as you wish. Please rate a student's performance relative to his/her level of academic and clinical experience. That is, students at the end of their first year of graduate study would not be expected to demonstrate the same level of skill and knowledge as those during their final semester externship experience.

Please use the following scale to rate a student's performance on the various items listed.

None =	Not Observed
0 =	Unsatisfactory
1=	Below Expected Level
2=	At Expected Level
3=	Exceeds Expected Level

1. CLINICAL SKILLS (70%)

	Mid-Term	Final
A. Diagnostics
1.01 Selects appropriate tests for administration	none 0 1 2 3	none 0 1 2 3
1.02 Explains tests procedures & rationales clearly & accurately	none 0 1 2 3	none 0 1 2 3
1.03 Administers tests accurately	none 0 1 2 3	none 0 1 2 3
1.04 Demonstrates flexibility during testing	none 0 1 2 3	none 0 1 2 3
1.05 Interprets test results accurately	none 0 1 2 3	none 0 1 2 3
1.06 Integrates observations and tests results into a diagnosis	none 0 1 2 3	none 0 1 2 3
1.07 Develops appropriate impressions	none 0 1 2 3	none 0 1 2 3
1.08 Develops appropriate recommendations	none 0 1 2 3	none 0 1 2 3
Demonstrates appropriate skill level with the following:
1.09 Pediatric testing	none 0 1 2 3	none 0 1 2 3
1.10 Behavioral testing	none 0 1 2 3	none 0 1 2 3
1.11 Electrophysiological testing	none 0 1 2 3	none 0 1 2 3
1.12 Other	none 0 1 2 3	none 0 1 2 3
B. Prosthetics
Amplification Devices
2.01 Demonstrates appropriate knowledge	none 0 1 2 3	none 0 1 2 3
2.02 Selects devices appropriately	none 0 1 2 3	none 0 1 2 3
Prescription Procedures
2.03 Demonstrates appropriate knowledge	none 0 1 2 3	none 0 1 2 3
2.04 Selects appropriate amplification parameters	none 0 1 2 3	none 0 1 2 3
Verification/Evaluation Procedures
2.05 Demonstrates appropriate knowledge	none 0 1 2 3	none 0 1 2 3
2.06 Applies procedures appropriately	none 0 1 2 3	none 0 1 2 3
Electroacoustic Measurements
2.07 Performs accurately	none 0 1 2 3	none 0 1 2 3
2.08 Interprets accurately	none 0 1 2 3	none 0 1 2 3
Real Ear Measurements
2.09 Performs accurately	none 0 1 2 3	none 0 1 2 3
2.10 Interprets appropriately	none 0 1 2 3	none 0 1 2 3
2.11 Performs hearing aid orientation appropriately	none 0 1 2 3	none 0 1 2 3
2.12 Explains procedures and rationales clearly and accurately	none 0 1 2 3	none 0 1 2 3
2.13 Other	none 0 1 2 3	none 0 1 2 3
C. Treatment Competencies
3.01 Develops and appropriate treatment plan	none 0 1 2 3	none 0 1 2 3
3.02 Chooses appropriate materials	none 0 1 2 3	none 0 1 2 3
3.03 Explains tasks and rationale clearly & accurately	none 0 1 2 3	none 0 1 2 3
3.04 Judges/interprets responses accurately	none 0 1 2 3	none 0 1 2 3
3.05 Provides accurate feedback	none 0 1 2 3	none 0 1 2 3
3.06 Facilitates appropriate client responses/behaviors	none 0 1 2 3	none 0 1 2 3
3.07 Maintains appropriate records	none 0 1 2 3	none 0 1 2 3
3.08 Other	none 0 1 2 3	none 0 1 2 3

2. COMMUNICATION (20%)

	Mid-Term	Final
A. Report Writing
1.01 Organization	none 0 1 2 3	none 0 1 2 3
1.02 Results of testing	none 0 1 2 3	none 0 1 2 3
1.03 Summary/Impressions	none 0 1 2 3	none 0 1 2 3
1.04 Recommendations	none 0 1 2 3	none 0 1 2 3
B. Conferencing
2.01 Ability to organize thoughts	none 0 1 2 3	none 0 1 2 3
2.02 Clearly conveys impressions and recommendations	none 0 1 2 3	none 0 1 2 3
2.03 Answers questions appropriately	none 0 1 2 3	none 0 1 2 3

3. PROFESSIONALISM (10%)

	Mid-Term	Final
A. Independence
1.01 Takes initiative	none 0 1 2 3	none 0 1 2 3
1.02 Preparation	none 0 1 2 3	none 0 1 2 3
1.03 Knows when to seek assistance	none 0 1 2 3	none 0 1 2 3
B. Interpersonal Skills
2.01 Relates to clients	none 0 1 2 3	none 0 1 2 3
2.02 Responsive to supervisor	none 0 1 2 3	none 0 1 2 3
2.03 Relates to other professional staff	none 0 1 2 3	none 0 1 2 3
C. Professionalism
3.01 Timeliness	none 0 1 2 3	none 0 1 2 3
3.02 Punctuality/Appearance	none 0 1 2 3	none 0 1 2 3
3.03 Openness to supervision	none 0 1 2 3	none 0 1 2 3

ADDITIONAL COMMENTS: