This form provides a succinct summary of all clinical hours of service completed in practicum and internship clinical placements, and can serve as a permanent record for clinical placement sites, institutions and for students as they seek licensure. Service hours are categorized as either Direct or Indirect.

The form should be endorsed by both site and faculty supervisors and can be available for CACREP reviewers as evidence of student success and in meeting Standard 3.F.G.J. & K.