CPSA – 1
Clinical Practicum Student Assessment (CPSA) CDIS 503 Practicum III
Semester:  Fall
Year: ___________
 Spring
 Mid-Term
 Summer
 Final
The CPSA is a survey-based tool designed to measure clinical performance based on general and specific competencies outlined in the KASA
standards set forth by ASHA and the skills outcomes determined by the ENMU Communicative Disorders Program. In order to complete the CPSA
you will need to indicate your student clinician's practicum level (i.e., CDIS 501, 502, 503, 505, or 589). Please ask your student clinician to supply
this information prior to beginning the CPSA.
It is recommended that your student clinician print a copy of the assessment and self-rate their competencies prior to meeting with you.
Reviewing and comparing the student clinician's ratings to your own is a good way to start a discussion about their clinical performance. After you
have met with your student, you will post your CPSA ratings online.
When you are ready to post your ratings, use the CPSA link that was sent to you to open the online CPSA survey. Completing the CPSA online will
take about 5-10 minutes. Spaces for your comments have been provided, but are not required. While completing the CPSA you may move forward
and backwards in a section without losing your responses. In addition, you may go back to previous pages and update your responses until the
CPSA is submitted or exited. There is a save option on the final page if you would like a copy of the CPSA for your records.
Please submit a separate CPSA for each practicum student you are supervising.
Thank you for serving as a clinical supervisor. Because of your willingness to train and mentor future SLPs, our program is able provide a diverse
learning experience for our students. Effective real-world clinical instruction helps to promote the development of critical thinking, problemsolving skills, and self-analysis. We sincerely appreciate your contribution to the clinical education process.
BACKGROUND INFORMATION:
Student Clinician: _______________________________________________________________________________________________________
Supervisor: ____________________________________________________________________________________________________________
Name of Site:___________________________________________________________________________________________________________
Type (Clinic, K-12, SNF, Hospital, etc.): ______________________________________________________________________________________
Location (City/State): ____________________________________________________________________________________________________
Rev. 06/15
CPSA – 2
ATTENDANCE POLICY:
Students are required to abide by the Practicum Schedule submitted at the beginning of the practicum experience. Students are expected to
conduct all personal business outside of scheduled days at the practicum site. If unable to report to practicum as scheduled, the student must
contact BOTH the site supervisor and the CDIS clinical director for approval of the absence. Excused absences will only be granted for major
events such as illness, family death, etc. and must be substantiated with appropriate documentation (e.g., a doctor’s note). Missed or cancelled
therapy appointments must be made up if required by the supervisor, as patient and/or supervisor’s schedules allow. Practicum days cancelled by
the supervisor are considered excused absences and do not need to be reported.
Did your student clinician miss any scheduled days or times at the practicum site?
 Yes
 No
If yes, please list the dates and reasons for each absence below.
Date ____________ Reason for absence ____________________________________________________________________________________
Date ____________ Reason for absence ____________________________________________________________________________________
Date ____________ Reason for absence ____________________________________________________________________________________
(Please list additional absences on the back of the form.)
Did your student clinician provide advance notice in a timely manner?
 Yes
 No
 N/A
CLINICAL EXPERIENCES:
Did your student clinician complete any screenings and/or evaluations in addition to providing therapy services?
 Yes
 No
If you selected No, skip to the following page.
Did your student clinician complete any screenings?
 Yes
 No
If you selected yes, complete the SCREENING COMPETENCIES worksheet and attach it to this document.
Did your student clinician complete any evaluations?
 Yes
 No
If you selected yes, complete the EVALUATION COMPETENCIES worksheet and attach it to this document.
Rev. 06/15
CPSA – 3
ADMINISTRATIVE COMPETENCIES:
Indicate your student clinician's level of competency for each of the items listed below, based on the following definitions:
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Marginal – Needs up to 100% assistance/feedback: Demonstrates little to no skill; Inability to make changes without explicit direction and/or demonstration
Emergent – Needs up to 75% assistance/feedback: Demonstrates minimal skill; Regularly needs specific direction and/or demonstration
Developing – Needs up to 50% assistance/feedback: Demonstrates evolving skill; Often needs some general direction and/or demonstration
Proficient – Needs up to 25% assistance/feedback: Demonstrates established skill; Occasionally needs direction and/or demonstration
Mastery – Independent with minimal assistance/feedback: Demonstrates superior skill; Takes initiative and performs effectively.
N/A: No opportunity
Yes
No
N/A
AC-01 Demonstrates punctual and consistent attendance at therapy sessions, supervisory and/or clinician meetings, and
other relevant appointments
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AC-02 Contacts the ENMU Clinical Director and the site supervisor as early as possible prior to an absence (excused
absences include: illness or family emergency)
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AC-03 Communicates with the supervisor regarding any changes in the client's schedule (e.g., scheduled appointments,
therapy cancellations, no shows, etc.)
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AC-04 Maintains/manages professional records in a confidential manner (e.g., tracking clock hours, copying/faxing,
following copyright guidelines, etc.) per site policy
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AC-05 Completes clinical assignments, written documentation, reports, etc., completely and thoroughly in a timely
manner, per site policy
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AC-06 Files clinical notes, therapy logs, time logs, etc., as required before leaving the site each day, per site policy
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AC-07 Demonstrates adequate knowledge of HIPAA and FERPA regulations/guidelines, and follows client confidentiality
policies at each site
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AC-08 Complies with site regulations, policies, and procedures (e.g. use of credentials/name badge, cell phone usage,
email policies, parking permit, fraudulent practices, carrying weapons, etc.)
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AC-09 Does not waste site resources (e.g., does not copy and/or print unnecessary or personal documents, controls
excess use of consumable supplies, materials, protocols, etc.)
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AC-10 Demonstrates knowledge of infection control/universal precautions and hand washing procedures, and
implements hygienic practices at each site
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AC-11 Maintains a clean therapy environment (e.g., sanitizing toys/materials after use, washing tables, rearranging
furniture, etc.) per site policy
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Rev. 06/15
CPSA – 4
Yes
No
N/A
AC-12 Follows procedures for materials use (checking out and returning materials promptly, organizing materials before
returning, and reporting damaged or missing parts, etc.)
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AC-13 Follows dress code and appearance requirements by dressing appropriately for the site (e.g., no visible
tattoos/piercings, distracting hair styles, excessive jewelry, etc.), per site policy
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AC-14 Does not report to a site or return to a site unless accompanied by a supervisor
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AC-15 Waits for clients and/or supervisor in designated area per site policy
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Comments regarding administrative competencies:
Rev. 06/15
CPSA – 5
PROFESSIONAL COMPETENCIES:
Indicate your student clinician's level of competency for each of the items listed below, based on the following definitions:
1.
2.
3.
4.
6.
Marginal – Needs up to 100% assistance/feedback: Demonstrates little to no skill; Inability to make changes without explicit direction and/or demonstration
Emergent – Needs up to 75% assistance/feedback: Demonstrates minimal skill; Regularly needs specific direction and/or demonstration
Developing – Needs up to 50% assistance/feedback: Demonstrates evolving skill; Often needs some general direction and/or demonstration
Proficient – Needs up to 25% assistance/feedback: Demonstrates established skill; Occasionally needs direction and/or demonstration
Mastery – Independent with minimal assistance/feedback: Demonstrates superior skill; Takes initiative and performs effectively.
N/A: No opportunity
Yes
No
N/A
PC-01 Demonstrates knowledge of and works within practice guidelines and the ASHA Code of Ethics
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PC-02 Demonstrates a positive clinical/professional demeanor with clients, families, supervisors, other professionals, and
other student professionals
PC-03 Demonstrates cultural competence when interacting with clients, families, supervisor, other professionals, and
other student professionals
PC-04 Implements prevention and/or conflict management strategies with clients, families, supervisor, other
professionals, and other student professionals
PC-05 Maintains and manages clinical records/charts in a confidential manner (e.g., chart access, real time
documentation, charting, etc.), per site policies
PC-06 Demonstrates adequate knowledge of client's file prior to assessment and/or intervention planning and
implementation
PC-07 Researches the client’s condition independently to design an intervention using an Evidence Based Practice (EBP)
framework
PC-08 Collaborates with the clients, families, supervisors, other professionals, and other student professionals to initiate
and improve clinical services
PC-09 Demonstrates adequate preparation for therapy by determining session objectives, selecting activities/materials,
and completing therapy logs/lesson plans prior to the session
PC-10 Works independently but seeks guidance as appropriate to the practicum level (I, II, III, IV), supervisor
requirements, and site policies
PC-11 Works to improve productivity (does not waste time) by planning, conducting, and concluding sessions in an
organized manner
PC-12 Ensures that clinical equipment is operational prior to use, and reports malfunctioning/damaged equipment to
appropriate personnel
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Rev. 06/15
CPSA – 6
Yes
No
N/A
PC-13 Does not unnecessarily disrupt the therapy session unless consulting with the supervisor or completing other
authorized procedures
PC-14 Does not incorporate food/drink in the therapy session unless indicated in the therapy plan and approved by
supervisor
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PC-15 Does not eat or drink in the presence of the client (this includes chewing gum)
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PC-16 Documents post session data related to outcomes, implementation of session objection, self-reflection, etc.) and
presents oral summary to the supervisor after the session, as required
PC-17 Listens and responds professionally to supervisor criticism/critique and communicates productively to find
collaborative solutions and/or resolve issues
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PC-18 Implements explicit supervisor instructions and/or recommendations as directed
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PC-19 Does not discuss clinical performance with the client, family, or other professionals without the supervisor being
present or without prior supervisor approval
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PC-20 Does not overstep professional boundaries by independently contacting clients/families off site, interacting
through social media, giving professional advice, making prognostic statements, providing clinical services , etc.
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Comments regarding professional competencies:
Rev. 06/15
CPSA – 7
INTERVENTION COMPETENCIES:
When rating your student clinician’s competencies as listed below, please consider the following factors:
A. The level of client involvement:
Level I: Mildly affected
Level II: Moderately affected
Level III: Severely to profoundly affected
B. The practicum level that your student clinician is enrolled in, as defined below:
INTERVENTION COMPETENCIES: CDIS 503 Practicum III
 Practicum experiences may be obtained at the ENMU SHROC, at sites that are directly supervised by ENMU CDIS faculty or at off-campus
sites such as public schools, skilled nursing facilities, home health agencies, and outpatient hospitals/clinics and rehabilitation centers
 Working with more challenging birth to three clients or with individuals who are medically fragile is also appropriate
o 1 credit: deliver treatment to more advanced clients in a single setting and participate in assigned evaluation/assessment teams
o 2 credits: deliver treatment to multiple clients/more advanced clients at a single setting and lead introductory level
evaluation/assessment teams
o 3 credits: deliver treatment to multiple clients/more advanced clients in a single setting or multiple settings, and lead introductory level
evaluation/assessment teams or complete introductory level assessments independently
CDIS 503 INTERVENTION COMPETENCIES:
Indicate your student clinician's level of competency for each of the items listed below, based on the following definitions:
1.
2.
3.
4.
5.
Marginal – Needs up to 100% assistance/feedback: Demonstrates little to no skill; Inability to make changes without explicit direction and/or demonstration
Emergent – Needs up to 75% assistance/feedback: Demonstrates minimal skill; Regularly needs specific direction and/or demonstration
Developing – Needs up to 50% assistance/feedback: Demonstrates evolving skill; Often needs some general direction and/or demonstration
Proficient – Needs up to 25% assistance/feedback: Demonstrates established skill; Occasionally needs direction and/or demonstration
Mastery – Independent with minimal assistance/feedback: Demonstrates superior skill; Takes initiative and performs effectively.
N/A: No opportunity
1
2
3
4
5
N/A
P3-01 Develops intervention plans appropriate to client's level of involvement
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P3-02 Develops focused goals/objectives
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P3-03 Matches materials and techniques to session targets and clients
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P3-04 Plans and implements flexible and responsive therapy
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P3-05 Manages unexpected and novel client behaviors
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Rev. 06/15
CPSA – 8
1
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5
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P3-06 Efficiently elicits multiple targets in a single session
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P3-07 Adapts therapy based on client performance during the session
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P3-08 Collects, analyzes, and synthesizes data accurately and efficiently
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P3-09 Reports data efficiently (in both oral and written formats)
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P3-10 Participates in client education and/or conferences in a variety of settings
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Comments regarding intervention competencies:
ADDITIONAL COMMENTS:
Please use this space to make additional comments that you feel are relevant to the evaluation of your student clinician's performance.
Please use this space to make additional comments or suggestions about your experience as a clinical supervisor, the assessment process,
this assessment tool, etc.
Rev. 06/15