SPEECH-LANGUAGE PATHOLOGIST LEARNING PLAN Name

Last

First

SLP Certificate #

Date

This form is to be used by DORA certified speech-language pathologists as a tool to develop, complete, and document professional learning goals. State your learning goals based on the Reflective Self-Assessment Tool (RSAT) and develop your Learning Plan using the “Planned Start/End Date” fields. Although 10 hours per renewal period are required, no more than 5 hours in any one category will be credited to the Learning Plan, except Coursework*. activities completed may differ from the original plan, but should still be relevant to established learning goals. The “Start/End Date” should reflect the first time and the last time the activity was done. This may encompass more than one occasion of participation in that particular activity. For example, if volunteer work was done on two separate days, the “Start Date” would reflect the first day of participation in volunteer work and the “End Date” would reflect the last day of participation in volunteer work. This form and supporting documentation is to be submitted only upon request.

Learning Goal #1 (Copy here from the results of your RSAT.)

Learning Goal #2 (Copy here from the results of your RSAT.)

If you created more than 2 goals, print additional Learning Plan forms and attach to this form. See the Categories for Professional Development Activities (PDA) List and the Continuing Professional Competency Program Manual for explanations of PDA categories. Go to the Speech-Language Pathologist web page at www.colorado.gov/dora/Speech-Language_Pathology_CPC.

PDA Category

Planned Start Date

Planned End Date

Actual Start Date (Required)

Actual End Date (Required)

Hours Completed

No more than 5 hours per activity will be credited.

Do you have documentation? Yes or No

Volunteer Service Mentoring/Supervision Presenting Coursework* Independent Learning Group Study Total Hours: I understand that under Colorado Speech-Language Pathology Board Rule 9(G), falsifying an attestation or other documentation regarding the certificate holder’s compliance with continuing professional competency requirements constitutes the falsification of information in an application and may be grounds for discipline pursuant to section 12-43.7-110(2)(B) and (K), C.R.S. If required to do so, I am able to and will submit documentation of my Continuing Professional Development, Active Military Duty or Deemed Status upon the Director’s request. Signature

* All 10 PDA can be accrued in the category of Coursework.

Date

Rev. 10/2017

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SPEECH-LANGUAGE PATHOLOGIST OPTIONAL ORGANIZATIONAL TOOL PDA Category

Learning Activity

Hours Completed

Date Completed

Examples: Volunteer Services

Participated on planning committee for annual convention

1 hour

12/02/2014

Volunteer Services

Volunteered at 9 Health Fair

4 hours

12/04/2014

* All 10 PDA can be accrued in the category of Coursework.

Rev. 10/2017

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