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ATTACHMENT F-1: Mentor’s Observation and Evaluation Form (Routes A & B Only)
(Direct Observation by a LSLS certified professional: 20 Sessions).
Name of Applicant:
________________
Name & designation of LSLS mentor:
Date of Observation:
__________
_________ Length of observed session: __________________________
Session Number: _______
Type of Session:
Classroom 
Individual 
Child(ren)’s Initials: __________ Age(s): __________
Parent Guidance 
Device(s):
__________
Other Relevant Information:
_____________________
Please provide feedback on the applicant’s current abilities in the following categories, using the
below rating scale as a guide for each (a completed evaluation form is mandatory for 20 required
sessions):
Rate the applicant for all relevant points below, using the following rating scale for items relevant to
the session. The mentor may omit topics or behaviors that were not evident in this particular session:
1 = Needs Improvement 2 = Adequate 3 = Competent 4= Superior N/O = Not Observed in Session
PLANNING INCLUDES:
_____ 1. Individualized instructional plan
_____ 2. Long-term instructional goals
_____ 3. Specific short-term objectives
_____ 4. Lesson plans with appropriate activities
_____ 5. Ideas for carryover of goals into daily experience
_____ 6. Specific parent’s guidance/engagement content
LSLS Certified Application
©2011 AG Bell Academy for Listening and Spoken Language
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ATTACHMENT F-1 (page 2)
SETTING:
_____ 1. Materials/activities organized and appropriate
_____ 2. Favorable acoustic environment
_____ 3. Favorable learning environment
_____ 4. Proper function and use of hearing technology
LISTENING AND SPOKEN LANGUAGE TECHNIQUES:
Audition
_____ 1. Maximizes auditory stimulation throughout (incidental learning, structured activities)
_____ 2. Integrates child’s audiological and speech perception information into daily practice
_____ 3. Uses appropriate acoustic highlighting
_____ 4. Promotes integration of listening and spoken language into the therapy/teaching activities
_____ 5. Adjusts expectations and targets as needed
_____ 6. Demonstrates thorough knowledge of auditory hierarchies
_____ 7. Develops auditory feedback loop
_____ 8. Uses wait time for child’s processing on input
Speech Production and Expressive Language:
_____1. Uses appropriate eliciting, prompting and modeling techniques
_____2. Provides wait time to encourage the child to talk
_____3. Appropriately accepts/corrects child’s productions in spontaneous conversation.
_____4. Demonstrates thorough knowledge of language hierarchies
_____5. Provides opportunities for language learning/use conversational situations
LSLS Certified Application
©2011 AG Bell Academy for Listening and Spoken Language
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ATTACHMENT F-1 (page 3)
_____6. Demonstrates thorough knowledge of speech hierarchies
_____7. Maximizes speech production in appropriate daily practice (phonetic, phonologic)
_____8. Uses a wide range of techniques for eliciting new sounds
General:
_____1. Effectively manages behavior
_____2. Maintain appropriates pacing
_____3. Focuses on improving child’s performance
PARENT GUIDANCE AND PARTICIPATION:
_____ 1. Engages the parent(s) according to the parent’s learning style
_____ 2. Uses a respectful and encouraging manner
_____ 3. Is flexible and responsive to parent’s input
_____ 4. Accommodates for different family structures and diversities
_____ 5. Organizes session to support participation and engagement
_____ 6. Provides parents with information and specific strategies/techniques
_____ 7. Provides timely, authentic feedback
LSLS Certified Application
©2011 AG Bell Academy for Listening and Spoken Language
32
ATTACHMENT F-1 (page 4)
DIAGNOSTIC AND REPORTING SKILLS:
_____ 1. Demonstrates informal, ongoing assessment of child’s progress (diagnostic teaching)
_____ 2. Maintains accurate progress notes
_____ 3. Adjusts teaching activities/strategies in accordance with child’s responses
_____ 4. Prepares quality progress reports
_____ 5. Provides parents and professionals with clear, comprehensible information regarding
assessments and interpretations of informal and standardized evaluations
_____ 6. Collects individual data on progress in all learning domains for each child
PROFESSIONAL QUALITIES:
_____ 1. Self-evaluates
_____ 2. Responds appropriately to observation and feedback
_____ 3. Develops appropriate relationships with colleagues, parents and other professionals
_____ 4. Displays a positive and enthusiastic attitude toward child/parents/professionals
_____ 5. Displays appropriate sense of humor
_____ 6. Displays confidence when being observed
_____ 7. Demonstrates knowledge of other educational options
_____ 8. Refers parents to other professionals when appropriate
_____ 9. Promotes practice of audiologic management as specified in the AG Bell Academy for
Listening and Spoken Language Recommended Protocol for Audiologic Assessment, Hearing
Aid Evaluation and Cochlear Implant Monitoring
_____ 10. Uses appropriate voice and speech patterns
_____ 11. Provides intervention consistent with the Principles of Listening and Spoken Language
Specialists
LSLS Certified Application
©2011 AG Bell Academy for Listening and Spoken Language
33
ATTACHMENT F-1 (page 5)
Overall Commendations for this session:
Overall Recommendations for Improvement for this session:
____________________________
Name of LSLS Mentor
__________
Date
_________________________ _________
Signature of Applicant
Date
Duplicate this form as necessary. A total of 20 evaluation forms are mandatory (one for each
mentored session).
I attest that the information disclosed on this form is correct, accurate, complete and made in good
faith. I understand that the Academy reserves the right to verify any or all information on this
application and that any incorrect or misleading information may constitute grounds for rejection of
the professional seeking certification’s application, revocation of my certification or other disciplinary
action.
______
Signature of LSLS mentor completing this form
____________________
Date
LSLS Certified Application
©2011 AG Bell Academy for Listening and Spoken Language
34