Student Forms

Clinic Forms

These forms are used for on-campus clinical practica. 

Forms A (Accidental)
A-01 Incident Report (pdf or doc) (For use by graduate student clinicians to document incidents occurring during clinic)

Forms F (Forms for Client Files)
F-20 Affirmation of Clients' Rights (pdf or doc)
F-20S Affirmation of Clients' Rights - Spanish (pdf or doc)
F-21 Daily Therapy Log (pdf or doc) (a.k.a. SOAP Notes)
F-22 Speech-Language-Hearing Evaluation Report (pdf or doc)
F-22A Speech-Language-Hearing Screening Report (pdf or doc)
F-24A Speech-Language Therapy Report (pdf or doc)
F-25 Client Recommendations (pdf or doc)
F-27 Statement of Understanding (pdf or doc)
F-27S Statement of Understanding - Spanish (pdf or doc)
F-28 Release for Exchange of Information (pdf or doc)
F-39 Adult Client History Form (pdf or doc)
F-40 Child Client History Form (pdf or doc)

Forms SC (Student Clinicians)
Correspondance Notes (pdf or doc)
KASA Form for the Evaluation of Student Performance (pdf or doc)
Professionalism Guide
SC-01 Speech and Hearing Screening Checklist (pdf or doc)
SC-03 Intended Therapy Plan (ITP) (pdf or doc)
SC-03M Intended Therapy Plan (ITP) for Bayshore Elementary School District (pdf or doc)
SC-06 Propose Therapy Objectives (PTO) (pdf or doc)
SC-10 Clinical Clock Hours (pdf or doc)
SC-10.5 Observation Clock Hours (pdf or doc)
SC-12 Speech Language Pathology Worksheet
SC-18 Client Interview Form (pdf or doc)
Client Privacy and Confidentiality Policy (pdf)

Forms HC (Hearing Conservation)
HC-01 Client History
HC-02 Audiogram
HC-03 Employee Notification Report of Hearing

Forms HS (Hearing Screening)
HS-01 Hearing Screening Form


Clinical Clock Hours Tracking

As you move through the program, you will gain clock hour experiences that collectively satisfy ASHA, California License, and California Credential requirements. To help you keep track of these hours, we have created a Clock Hours Tracking Spreadsheet for you to download and use . When you enter your clock hours in blue cells of the spreadsheet, they are automatically tallied and compared against the requirements you are expected to meet. In most cases, you will require the majority of your clinical clock hours across the following contexts: a) your on-campus clinics (typically 80-100 hours total), b) school & medical internships (typically 250+ hours total), c) observations hours (up to 25 hours), d) audiometry (up to 75 hours). To learn more about clinical clock hours, please see

» Download the CD Program Clock Hours Tracking Spreadsheet


Knowledge And Skills Acquisition (KASA) Forms 

Students keep track of their attainment of ASHA standards throughout the program using the "long" Knowledge and Skills Acquisition (KASA) form. (Note: Adjust your print settings to landscape before printing this form.) It summarizes a student's acquisition of the knowledge and skills delineated in the Standards for the Certificate of Clinical Competence (CCC). Entries are made only upon acquisition of the knowledge or skill; thus the KASA is not an evaluation, but only a record that a particular knowledge or skill has been acquired. There is also a "short" KASA form that clinical supervisors use to assess your clinical skills at the end of the semester. For more information about the KASA, please see

>> Download the long KASA form

>> Download the short KASA form