Postgraduate Professional:

Name

Address

Phone

Social Security #

Area of Licensure Sought:

SLP       AUD

PPE Supervisor:

Name

Address

Do you have:

ASHA Certification

SLP       AUD       Account #:

WV License

SLP       AUD       License #:

Other License

PPE Setting:

Faculty Name:

Address:

Phone:

Anticipated Beginning Date:

Anticipated Ending Date:

Hours per week to be worked in:

Speech-Language Pathology

Audiology

PPE Professional Experience:

Determine the length of the PPE and indicate the hours per week to be worked below:
Nine months of full-time professional employment of at least 30 hours per week.
Twelve months of part-time professional employment of at least 25hours per week.
Fifteen months of part-time professional employment of at least 20 hours per week.
Eighteen months of part-time professional employment of at least 15hours per week.

Specify how many hours per week will be spent in the activities listed below. It is the interpretation of the WVBESLPA that at least 80% of the PPE work week must be in direct client contact (assessment/diagnosis/evaluation, screening, habilitation/rehabilitation) and activities related to client management.
Evaluation (includes assessment, diagnosis, and screening)
Habilitation/rehabilitation
Activities related to client management (includes client reports, client conferences, family counseling, etc.)
In-service training
Other (specify)

Plan for at least 36 supervisory activities during the entire PPE, including 18 hours of on-site observation and 18 other monitoring activities. Allow for minimum of 6 hours of on-site observation during each one-third segment of the PPE and at least one other monitoring activity per month. Indicate the planned distribution of hours:
Total number of hours of on-site observation
Number of hours of on-site observation
      1st segment      2nd segment      3rd segment
Total number of other monitoring activities
At least one monitoring activity per month: Yes       No

Supervisor's Agreement

I, the PPE Supervisor, have read, discussed, and agreed upon all Sections listed above, including the direct expense reimbursement. Furthermore, I verify that my CCC is current and will be maintained during the PPE. I have read the "PPE Supervisors' Responsibilities." I agree to approve/disapprove, sign, and submit a Postgraduate Professional form to the WVBESLPA within 30 days of completion of the PPE experience. I will fulfill this responsibility even if I am unable to approve the PPE experience.

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Postgraduate Professional Agreement

I, the Clinical Fellow, have read, discussed and agreed upon all Sections listed above. I have verified that my PPE Supervisor holds a current West Virginia license in the appropriate area. If it is later determined that this is not correct, I, not WVBESLPA, assume full responsibility for an invalid PPE experience. I have read and provided my PPE Supervisor with a copy of the "PPE Supervisors' Responsibilities." I have read and agree to abide by the WVBESLPA Code of Ethics.

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