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Clinical education forms 2013-14
Clinical Speech & Language Studies, Trinity College, Dublin
Clinical education forms 2013-14
Preclinical Professional conduct Agreement and report 6
Practice placements: General conduct agreement 8
Student declaration and Health and Safety agreement 10
Assessment experience log 12
Reflective log 1 14
Reflective log 2 Post therapy session 15
Clinical Competency Evaluation form: Clinical Session 17
Student clinical placement evaluation 19
Notification of concern: Professional conduct SF JS SS 21
Notification of Concern Competency development SF JS SS 22
Clinical learning self review 24
Clinical learning self review (detailed) 27
Portfolio for feeding, eating, drinking and swallowing / dysphagia assessment and management 37
FEDS portfolio evaluation 38
Oral examination 39
Audiogram 42
Junior Freshman Annual hours certification form 44
Junior Freshman CONNECT Summary 45
PDL Clinical learning Self review form Junior Freshman 47
Student Mid placement Self review form Senior Freshman 48
Senior Freshman Evaluation of assessment skills 52
Detailed evaluation of a test in current clinical use 54
Test review form 56
Senior Freshman Communication Assessment Pack 58
Reflective log 2 Assessment protocol trial session 59
Daily hours certification log Senior Freshman Term Clinic 60
Senior Freshman Term hours certification form 62
Senior Freshman Assessment and case management Summary marks 64
Senior Freshman Case presentation evaluation 66
Senior Freshman Case presentation evaluation (FEDS) 67
Senior Freshman Assessment Case Report (FEDS) evaluation 69
Senior Freshman Assessment Case Report evaluation 70
Daily hours certification log Senior Freshman Block Clinic 71
Senior Freshman Block hours certification form 73
PDL Evaluation form Senior Freshman 75
SF/JS Service and caseload report evaluation Oral presentation 77
Student Mid placement Self review form Junior Sophister 79
Junior Sophister Daily hours certification log (Term Clinic) 82
Junior Sophister Term hours certification form 84
Junior Sophister Clinical competency evaluation form: Clinical examination 86
Junior Sophister Case management 88
Continuous assessment and examination 88
Junior Sophister PDL submission form 90
Junior Sophister Daily hours certification log Block 92
Junior Sophister Block hours certification form 94
Junior Sophister Case report evaluation 96
Senior Sophister Daily hours certification log 98
Senior Sophister Term hours certification form 100
Student Mid placement self review form Senior Sophister 102
Senior Sophister 3.1 Continuous assessment 106
Senior Sophister PDL review 108
SS Daily hours certification form 110
Senior Sophister Block hours certification form 112
Senior Sophister Student Clinical Competency Clinical Examination 114
Senior Sophister Continuous assessment 117
The Student Clinical Competency Forms and Indicators and the FEDS log can be downloaded from http://www.tcd.ie/slscs/clinical-speech-language/practice-education/
Copies of the relevant forms will be sent with the student information pack prior to each placement. Students are given copies of all forms relevant to their year at clinical briefings in September.
Clinical education forms 2013-14
0A / Preclinical Professional conduct Agreement and reportAll
placements / A / Practice placements General conduct
B / Student declaration and Health and Safety agreement
C / Assessment experience log
D / Reflective log 1 & 2
E / Clinical competency evaluation form: Clinical session
F / Student clinical placement evaluation
G 1 / Notification of concern: Professional Conduct
G 2 / Notification of concern: Competency development
H / Clinical learning self review
I / Portfolio for feeding, eating, drinking and swallowing / dysphagia assessment and management
J / Student log for feeding, eating, drinking and swallowing
K / Oral examination JF/SF
L / Audiogram
JF / 0.1 / Annual hours certification form
0.2 / PDL Clinical learning review form
SF Weekly / 1 / Student Clinical Competency Evaluation Form and indicators Level 1 (Download as separate documents)
SF / 1.R / Student Mid placement review form Senior Freshman
SF / 1.a / Evaluation of assessment skills
SF / 1.b / Detailed evaluation of a test in current clinical use
SF/JS / 1.c / Test review form
SF / 1. AP / Senior Freshman Assessment Pack
SF / 1.1D / Daily hours certification log
SF / 1.1T / Term hours certification form
SF / 1.1.CA / Assessment and case management clinics Continuous assessment
SF / 1.1.P / Case presentation evaluation
SF / 1.1.R / Case report evaluation
SF / 1.2D / Daily hours certification log
SF / 1.2B / Block hours certification form
SF / 1 PDL / PDL learning review form
SF/JS / 1.2 P / Service report evaluation
2 / Student Clinical Competency Evaluation Form and indicators Level 2 (Download as separate documents)
2R / Student Mid placement review form Junior Sophister
JS Weekly / 2.1. D / Daily hours certification log
2.1 T / Term hours certification form
2.1 E / Junior Sophister Clinical examination
2.1CA / Junior Sophister Continuous assessment
JS / 2 PDL / PDL learning review form
JS Block / 2.2.D / Daily hours certification form
JS / 2.2.B / Block hours certification form
JS / 2.2.R / Case reports evaluation
SS / 3 / Student Clinical Competency Evaluation Form and indicators Level 3 (Down load as separate documents)
SS / 3R / Student Mid placement review form
SS / 3.1D / Daily hours certification form
SS / 3.1.T / Term hours certification form
SS / 3 PDL / PDL learning review form
SS / 3.1 CA / Senior Sophister Continuous assessment
SS Block / 3.2 D / Daily hours certification form
SS / 3.2 B / Block hours certification form
SS / 3.2 E / Student Clinical Competency Clinical Examination summary
SS / 3.2 CA / Senior Sophister Continuous assessment
0 A / Clinical Speech & Language Studies, Trinity College, Dublin
Preclinical Professional conduct Agreement and report
Students should sign this form prior to placements to confirm that they will comply with all national guidelines and with agency specific policies and procedures designed to protect and serve the needs of clients and retain this in their log. Practice educators may request a copy of the form from students for their own records. This form and the certified conduct record must be included and retained in the PDL until graduation.
Commitment / I agree to show commitment to clients, to the speech and language therapy service and to the host agency during all clinical placements.Preparation / I have read and understand the recommended readings for this placement including agency specific policies and procedures as recommended by the practice educators.
Conduct / I agree to adhere to the professional code of ethics and standards of conduct.
Health and safety / I agree to inform all relevant clinical educators of any condition, medical or otherwise, which may affect my clinical work. I will provide the practice educator with contact details of my next of kin in case of medical emergency. I will comply with agency specific health and safety procedures and with national guidelines for infection prevention and safety at work. I am familiar with the general safety and specific infection control/prevention procedures and guidelines that apply to this placement.
Confidentiality / I will maintain client, service, supervisor and peer confidentiality at all times. I will comply with agency policies in record keeping and use of information technology.
I confirm that I have complied with the Garda vetting procedure prior to registration.
Student Name print
Signature
Date
Professional Conduct
Students are expected to demonstrate a high level of professional conduct throughout their placement. Students should be made aware of any breaches in conduct as soon as they occur. Failure to maintain an acceptable level of professional conduct after one warning should be notified to the college. Persistent failure in any aspect of professional conduct will result in a student failing that placement.
Mid placement / End of placementAcceptable / Unacceptable / Acceptable / Unacceptable
Adheres to IASLT code of ethics
Communicates with clients in a professional manner
Obtains client consent in accordance with legal guidelines and the policies and procedures of the host agency
Maintains all aspects of client confidentiality in accordance with legal and professional guidelines
Maintains appropriate professional relationships with clients and carers
Maintains appropriate professional relationships with colleagues
Communicates with colleagues in a professional manner showing respect for their position, views and opinions
Refrains from disparaging or unprofessional comments about the competencies of colleagues
Adheres to the policies and procedures of the host agency e.g. health and safety, administration, record keeping etc.
Shows punctuality in attendance, meeting deadlines and managing clinic time effectively
Presents a professional image adhering to dress code and guidelines of the host agency
Recognises own professional limits and competencies and works within professional boundaries
Participates actively in developing own professional competencies
Warnings issued /date/PE /Student signature
Student signature
Practice Educator Signature
Date: (Mid) (End)
A / Clinical Speech & Language Studies, Trinity College, Dublin
Practice placements: General conduct agreement
Students should sign this form prior to placements to confirm that they will comply with all national guidelines and with agency specific policies and procedures designed to protect and serve the needs of clients and retain this in their log. Practice educators may request a copy of the form from students for their own records.
Health and safety
I am aware of, and will comply with the standard precautions and with guidelines for best practice in clinical contexts including
· General workplace risk assessment
· Hand Hygiene
· Use of protective barriers i.e. personal clothing, gloves, surgical masks
· Cleaning of surfaces and equipment with appropriate disinfectants
· Prevention and Control of Healthcare Associated Infections
I will comply with agency specific health and safety procedures as explained to me by the practice educators during my placement induction meeting and with national guidelines for infection prevention, record keeping and use of information technology.
Confidentiality
Students on practice placements are given access to client records and personnel data to enable them to carry out their work as speech and language therapy students. Students must conform to the legal and professional guidelines as outlined at the clinical briefing and summarized in the PDL. They must also comply with the confidentiality procedures of the Agency at which the placement is being undertaken
I have read and understand the information on confidentiality and health and safety during practice education and will comply with this during my placement in
(agency name).
I confirm that I have complied with the Garda vetting procedure prior to registration.
Student Name print
Signature
Date
Garda Vetting
Students of the College are required to comply with Garda vetting procedures prior to registration. If, as a result of the outcome of the Garda vetting procedures, a student is deemed unsuitable to attend clinical or other professional placement, he/she may be required to withdraw from his/her course Students should consult with the head of department should events occur during the education programme that may make them unsuitable for clinical or practice placements where they will come into contact with children or vulnerable adults (Calendar page H3 para 22).
I confirm that I have complied with the Garda vetting procedure prior to registration and have not endangered my status in the interim.
Student Name print
Signature
Date
Health and safety
Speech and language therapy students must adhere to the health and safety guidelines as determined by the Faculty of Health Sciences. These are stated as follows in the college regulations
Precautions against infectious diseases
Students in Medicine, Dentistry, Clinical Speech and Language Studies must be free of any life threatening infectious condition that could be transmitted to a to a patient or fellow health worker. Such conditions include Hepatitis B, Hepatitis C, pulmonary tuberculosis, chickenpox and measles. In the event of a student becoming aware of such a condition they should consult their medical advisor to confirm they are not contagious. If such be the case they should obtain a medical certificate confirming the diagnosis and should refrain from patient contact until cleared medically.
Certificate of vaccination status
In the interests of reducing the risk of the transmission of infectious disease from patients to students, or student to patient, all potential students should attend their regular medical practitioner prior to registration to certify their vaccination status or immunity to tuberculosis, measles, rubella and chickenpox.
Hepatitis B
In addition and in accordance with current guidelines from the Irish Department of Health and Children applicants seeking entry to courses where exposure -prone procedures are undertaken as a later part of the undergraduate training, namely Clinical Speech and Language Studies and Medicine, must produce a negative hepatitis B virus infection result (i.e. negative HbeAg, HbsAg and anti Hb core Ag tests ) carried out not more than six months prior to entry, before being permitted to register with the College. College Calendar 2012-13 pO2.5
Students must also adhere to all guidelines of the host agency as outlined to them at induction meetings.
B / Clinical Speech & Language Studies, Trinity College, DublinStudent declaration and Health and Safety agreement
Clinical placements provide opportunities for students to develop the basic knowledge and skills necessary to become competent practitioners. During placements, students are expected to adhere to professional standards and to conform to the policies and procedures of the host agency. Students are required to signal acceptance of their responsibilities by signing this agreement. The agreement is retained by the practice educator until the placement is completed.
Commitment / I agree to show commitment to clients, to the speech and language therapy service and to the host agency during all clinical placements.Conduct / I agree to adhere to the professional code of ethics and standards of conduct.
Clinical educators / I agree to prepare, organise and implement clinical work as directed by clinical educators and specifically by the practice educator who retains responsibility for the client.
Sickness/absence / I agree to follow the procedure set by College in the event of a medical or other emergency situation necessitating unexpected absence. I will give adequate notice to the placement education coordinator and to the relevant clinical educator if a planned absence is necessary. I will inform the placement education coordinator and the practice educator ASAP if I have to be unexpectedly absent due to illness.
Students who need to take more then two days sick leave during any placement must submit a medical certificate to the College Tutor. Students on medically certified leave should inform their practice educator and the practice education coordinator () of expected return date. Students who have to take prolonged medical leave may be required to submit a certificate of fitness to return to clinical practice.
Health and safety / I agree to inform all relevant clinical educators of any condition, medical or otherwise, which may affect my clinical work. I have provided the practice educator with my next of kin contact details. I am familiar with the general safety and specific infection control/prevention procedures and guidelines that apply to this placement.
Accidents / I will report any accident in the clinic or on the premises to the clinician immediately and follow the local accident reporting procedures.
Clinical equipment / I will not remove any tests or equipment from clinics and will ensure that all equipment used by me is clean, complete and returned to correct storage location following use.
Clinic files and records / I will conform to legal and professional guidelines and to the host agency procedures in maintaining clinical files. I will not remove files and other client records from any clinic.
Confidentiality / I will maintain client, service, supervisor and peer confidentiality at all times.
I confirm that I have read and accept the terms and conditions of my clinical placement as outlined above and as detailed in student handbooks.