Clinical Fellowship and Mentoring Survey

Please complete and return the following survey by February 10, 2005 
Mindy Karten Bornemann
United Federation of Teachers, 52 Broadway- 16th Floor, New York NY 10004
212-598-7774

Name ______________________________________________________

Personal e-mail Address ______________________________________________________

Home Address ______________________________________________________

School (s) ______________________________________________________

District Region ______________________________________________________

File Number ______________________________________________________

School Phone Number___________________ Home or Cell number ___________________

Please Complete and Check below:

___ BA- Speech Language Pathology or another bachelor’s degree

___ MS- Speech Language Pathology or another master’s degree

Do you have ___ provisional or ___ initial certification from the State Education Department?

Do you have ___ permanent state certification as a teacher of Speech and language disabilities
or ___ Teacher of the Speech and Hearing Handicapped?

Is this your ___ first or ___ second year working as a speech teacher?

Do you want to obtain your Certificate of Clinical Competence? ___ Yes   ___ No

When would you like to begin your Clinical Fellowship Year ____________ or have you begun already? ___ Yes

Who is your clinical supervisor? _______________________________________________________

Are you a licensed Speech Language Pathologist? ___ Yes   ___ No

Do you have ASHA Certification? ___ Yes   ___ No

Number of years working satisfactorily for the DOE? ___

Would you be willing to provide a Clinical Fellowship with a speech colleague in your district? ___ Yes   ___ No

Would you be willing to mentor a speech colleague in your district? ___ Yes   ___ No

Are you bilingual and do you have an ancillary license? ___ Yes   ___ No

What language _______________________________________________________
 
Thank you for your continued support and commitment to our chapter

January 2006 Issue