Instructions for Completing the Record of Diversity, Disorders, and Procedures as Part of Clinical Practicum

Students earning client contact hours should complete not only the Record of Client Contact Hours form but also the corresponding Record of Diversity form which provides documentation consistent with the 2005 ASHA standards for Knowledge and Skills Acquisition (KASA).

  • Students MUST keep in their possession TWO ORIGINAL CUMULATIVE forms.
  • At the end of each clinical practicum experience students fax a COPY of theinitialed original (and corresponding Record of Client Contact Hours) so that the program can track the student’s progress.Don’t send in an Original.

The subsections of the Record of Diversity are as follows:

  1. Clock Hours
  • Enter total clock hours for each age level or ethnicity on a separate line.
  • The hours marked on the Record of Diversity should match the hours marked on the corresponding Record of Client Contact Hours form for evaluation and treatment.
  1. Diversity
  • Client Age – The client age can be written as a specific age if one client, or an age level if more than one client is represented:
  • 0 – 6 years
  • 6 – 12 years
  • 12 – 18years
  • 18+ years
  • Culture/Ethnicity – Please enter one of the following codes: W= White, Non-Hispanic, AP=Asian-Pacific, AA=African-American, H=Hispanic, AI=American Indian, O=Other (you must state the ethnicity if choosing “Other”). Each ethnicity should have its own line.
  • Language Spoken: Please enter the language or languages here, including ASL. Do not use “O” or “other”, you must state the language.
  • Note: Clients may be grouped together if their age and ethnicities are similar. In this case, you can list as many things that you can fit into the therapy box.
  1. Disorder: Please check off the disorder according to the definitions posted on the form. If you are grouping more than one child together check all disorders that apply.
  2. Evaluation: Complete this area only if an evaluation was completed.
  • If a formal evaluation tool was used, please list the name of the tool under “Formal”.
  • If informal procedures were used, please describe under “Informal”. Informal procedures include parent report.
  • If no evaluation was performed, please leave this section blank.
  1. Treatment: Complete this section only if treatment was provided.
  • Please describe the methods, formal or informal treatment protocols, individual versus group, and style of therapy used.
  • The purpose of this section is to document the exposure our students have had to various treatment methods and styles appropriate to various diagnoses, cultures, ethnicities, and age groups.
  • “Direct”, “Indirect”, or “Formal” is not a sufficient description for this section. Here are some examples of appropriate documentation:
  • Receptive/ Expressive Language:

i.Structured play therapy with milieu approach, including mand modeling and recast for expressive language development.

ii.Indirect Language Stimulation activities (0-3 year old) directed at early functional communication words in categories of food, toys, directions (up, down, push me, etc).

iii.Traditional drill activities addressing singular and plural forms, is-verbing.

iv.Individual and Group Aphasia treatment: theme-based functional communication activities such as ordering take-out, describing daily routines, talking with physicians

  1. Articulation

i.Traditional Van Riper hierarchy applied to individual sounds in error.

ii.Oral Motor and Orofacial Exercises to address pre-speech muscle tome and movement

iii.Pacing or Melodic Intonation Therapy

iv.Place-Manner-Voicing approach to production, stabilization and carryover of sounds or sound groups

  1. Fluency:

i.Self-awareness education and feedback involving audio or videotaping

ii.Sound Prolongations

d. Social Communication:

i.Play-based activities with modeling and prompting for completion of circles of communication

  1. Cognitive-Linguistic:

i.Individual and Group Aphasia treatment: theme-based functional activities for planning, sequencing, memory, and problem-solving. Such activities may include planning a trip or party, sequencing a photo album from an activity, recalling recent events from the news, etc.