University of SouthFlorida

Audiology Evaluation Form - Year Four

NAME ______Site______

Supervisor ______Term ______

AREA / MIDTERM GRADE / FINAL GRADE
Letter / Numeric / Letter / Numeric
Interpersonal Communication
Planning
Assessment Skills-Adult
Assessment Skills-Pediatric
Assessment Skills-Specialty
Amplification
Counseling, Recommendations and Referrals
Written Documentation
Auditory/Vestibular Rehabilitation
Professionalism/
Clinical Problem Solving
SUBTOTAL
OVERALL AVERAGE GRADE
SCALE: A+ = 8.0-7.8 B+ = 5.9-5.0 C = 2.9-2.0
A = 7.7-7.0 B = 4.9-4.0 D/F = 1.9 and below
A- = 6.9-6.0 B- = 3.9-3.0

RATING SCALE with SUPERVISION CONTINUUM

Outstanding
A+ = 8 /

Excellent

A = 7 / Excellent
A- = 6 / Above Average
B+ = 5 /

Average

B = 4 / Below Average
B- = 3 /

Unsatisfactory

C = 2 /

Absent

D/F = 1
Competency
/skill well-developed and consistent.
Requires guidance and consultation only. / Competency
/skill developed but needs refinement. Requires infrequent monitoring. / Competency/
skill developed but needs refinement and consistency. Requires some monitoring. / Competency /
skill present but needs further development. Requires frequent monitoring. / Competency/skill demonstrated but inconsistent.
Requires frequent monitoring and occasional modeling. / Competency/
skill emerging but inconsistent.
Requires frequent monitoring and frequent modeling. / Competency/
skill demonstrated only with supervisor model . Requires constant monitoring and frequent modeling. / Competency/skill not evident.Requires constant monitoring and modeling.

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Instructions:

Circle the appropriate rating on the 8 point scale for each competency area.

A rating of “B” or better must be achieved in each competency area to demonstrate adequate performance.

The average of the ratings for the 10 competency areas is used to determine the overall clinical rating.

Indicate NA (not applicable) for areas that are unable to be assessed due to limited opportunities or exposure.

Interpersonal Communication /

Outstanding

/

Excellent

/

Excellent

/

Above

Average /

Average

/

Below Average

/

Unsatisfactory

/

Absent

A+=8
/ A=7 / A- =6 / B+= 5 / B=4 / B- =3 / C= 2 / D/F=1 / Midterm / Final
Effectively communicates and collaborates with patients, families, caregivers and other professionals. / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Planning /

Outstanding

/

Excellent

/

Excellent

/

Above

Average /

Average

/

Below Average

/

Unsatisfactory

/

Absent

A+=8
/ A=7 / A- =6 / B+= 5 / B=4 / B- =3 / C= 2 / D/F=1 / Midterm / Final
Conducts appropriate pre-assessment planning. / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Assessment Skills- Adult /

Outstanding

/

Excellent

/

Excellent

/

Above

Average /

Average

/

Below Average

/

Unsatisfactory

/

Absent

A+=8
/ A=7 / A- =6 / B+= 5 / B=4 / B- =3 / C= 2 / D/F=1 / Midterm / Final
Obtains a complete case history. / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Effectively conducts an adult hearing evaluation (air, bone & speech) with and without masking. / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Effectively conducts immittance measures. / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Effectively conducts otoacoustic emissions testing. / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Recognizes the need for cerumen removal. / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Average – Assessment Skills/Adult
Assessment Skills- Pediatric /

Outstanding

/

Excellent

/

Excellent

/

Above

Average /

Average

/

Below Average

/

Unsatisfactory

/

Absent

A+=8
/ A=7 / A- =6 / B+= 5 / B=4 / B- =3 / C= 2 / D/F=1 / Midterm / Final
Obtains a complete case history. / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Effectively conducts a developmentally appropriate pediatric hearing evaluation with and without masking. / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Effectively conducts immittance measures. / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Effectively conducts otoacoustic emissions testing. / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Recognizes the need for cerumen removal. / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Average – Assessment Skills/Pediatric
Assessment Skills- Specialty /

Outstanding

/

Excellent

/

Excellent

/

Above

Average /

Average

/

Below Average

/

Unsatisfactory

/

Absent

A+=8
/ A=7 / A- =6 / B+= 5 / B=4 / B- =3 / C= 2 / D/F=1 / Midterm / Final
Effectively conducts advanced assessment measures:
a. ABR/EcochG / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
b. ENG/VNG / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
c. Balance evaluation / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
d. Evoked potentials ((MLR, LLR) / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
e. Auditory processing evaluation / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Average – Assessment Skills/Specialty
Amplification /

Outstanding

/

Excellent

/

Excellent

/

Above

Average /

Average

/

Below Average

/

Unsatisfactory

/

Absent

A+=8
/ A=7 / A- =6 / B+= 5 / B=4 / B- =3 / C= 2 / D/F=1 / Midterm / Final
Appropriately recommends, selects, fits, maintains and troubleshoots:
a. Hearing aid(s) / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
b. Assistive listening device / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
c. Cochlear implant / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Average – Amplification
Counseling, Recommendations and Referrals /

Outstanding

/

Excellent

/

Excellent

/

Above

Average /

Average

/

Below Average

/

Unsatisfactory

/

Absent

A+=8
/ A=7 / A- =6 / B+= 5 / B=4 / B- =3 / C= 2 / D/F=1 / Midterm / Final
Provides appropriate counseling, follow-up recommendations and referrals. / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Written Documentation /

Outstanding

/

Excellent

/

Excellent

/

Above

Average /

Average

/

Below Average

/

Unsatisfactory

/

Absent

A+=8
/ A=7 / A- =6 / B+= 5 / B=4 / B- =3 / C= 2 / D/F=1 / Midterm / Final
Provides accurate and concise documentation (reports, chart notes, etc.). / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Auditory/Vestibular Rehabilitation /

Outstanding

/

Excellent

/

Excellent

/

Above

Average /

Average

/

Below Average

/

Unsatisfactory

/

Absent

A+=8
/ A=7 / A- =6 / B+= 5 / B=4 / B- =3 / C= 2 / D/F=1 / Midterm / Final
Implements, conducts and assesses appropriate rehabilitation measures:
a. Aural rehabilitation / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
b. Vestibular rehabilitation / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Average – Auditory/Vestibular Rehabilitation
PROFESSIONALISM/
CLINICAL PROBLEM SOLVING /

Outstanding

/

Excellent

/

Excellent

/

Above

Average /

Average

/

Below Average

/

Unsatisfactory

/

Absent

A+=8
/ A=7 / A- =6 / B+= 5 / B=4 / B- =3 / C= 2 / D/F=1 / Midterm / Final
Demonstrates professionalism. / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Demonstrates appropriate clinical problem solving abilities. / 8 / 7 / 6 / 5 / 4 / 3 / 2 / 1
Average – Professionalism/Clinical Problem Solving

AREAS OF STRENGTH

Midterm:

Final:

AREAS FOR FURTHER DEVELOPMENT

Midterm:

Final:

MIDTERM EVALUATIONFINAL EVALUATION

______

Graduate ClinicianGraduate Clinician

______

Site PreceptorSite Preceptor

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