Name:__________________________________  E-mail address:___________________

File #: ______________________ Home address: _______________________________

                                                                               _______________________________
Employment:

District: ______________________________ School: ___________________________

Location: _____________________________ # Years in System: __________________

# years as a speech improvement teacher____________   License Code: _____________

Status: PPT________      Provisional Certified________      Appointed_____________

Education:

Undergraduate degree in Communication Disorders:  Yes________  No_______

If degree is in another discipline, # undergraduate credits in Communication Disorders:______

Number of graduate credits in Communication Disorders earned since 1999: _______

Number of documented clinical observation hours:_________

Number of documented clinical assessment/treatment hours: __________

Check if you have taken a course in the following subjects:

    _____Biology/Physics            _____Developmental Psychology

    _____College Math              _____Anatomy & Physiology

    _____Phonetics                     _____Normal Speech and Language Development

    _____Linguistics                   _____Articulation Disorders

    _____Audiology                    _____Child Language Disorders

    _____Aural Rehabilitation      _____Augmentative-Alternative Communication
 

Are you bilingual? _____ What language? ________________________________

Do you have a Masters Degree? _____      In what area? __________________________