Continuing Education Form – The Four Stages of Imitation If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Please complete the form below to receive CEUs for your participation in the one-hour self-study course, The Four Stages of Imitation. Once your information is submitted, you will receive a reply email from us in 4-8 weeks containing your certificate of completion. Thank you! PARTICIPANT INFORMATION ENROLLMENT PIN * Your pin is included inside your DVD case. If you purchased your DVD before 11/30/17, please enter "123456" and we will verify your purchase manually. 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ASHA Account Number Or: Only if you are NOT an ASHA member, please complete the field below which is most appropriate. If you are not an ASHA member or CCC holder, you must be licensed or credentialed to practice speech-language pathology (SLP) or audiology or preparing to practice to earn ASHA CEUs. LICENSED - State and License # Only if you are NOT an ASHA member, please complete the field here which is most appropriate. CERTIFIED - State/Organization and # CLINICAL FELLOW - Supervisor Name and His/Her ASHA # STUDENT - Enrolled in a graduate program in SLP or audiology - University Name and Expected Graduation Date LEARNING ASSESSMENT Please feel free to reference your handout or the lecture while answering questions. The investigator who first identified the four stages of imitation was: * Please select...Peter LadefogedJean PiagetNoam Chomsky The goal of the first stage of imitation is to: * Please select...Imitate the therapistImitate the parentMake any sound The second stage, called Mutual Imitation, is characterized by: * Please select...No turn-taking behaviorTurn-taking initiated by the therapistTurn-taking initiated by the child The ability of the child to imitate the sounds he already can produce is called: * Please select...Spontaneous Imitation of Old RepertoireSpontaneous Imitation of New RepertoireSpontaneous Imitation of Recent Repertoire In the final stage, the child can imitate any novel sound or word. This emerges: * Please select...By 6 months of ageAround the first birthdayBy 2 years of age PROGRAM EVALUATION Please rate the following statements from 1 to 5 using the guide below. 1 = Strongly Disagree 2 = Somewhat Disagree 3 = Unsure 4 = Mostly Agree 5 = Strongly Agree 1 - Strongly Disagree 2 - Somewhat Disagree 3 - Unsure 4 - Mostly Agree 5 - Strongly Agree The material in this recorded seminar was practical to speech-language therapy. 1 - Strongly Disagree 2 - Somewhat Disagree 3 - Unsure 4 - Mostly Agree 5 - Strongly Agree The material presented in the seminar was well-organized. 1 - Strongly Disagree 2 - Somewhat Disagree 3 - Unsure 4 - Mostly Agree 5 - Strongly Agree The speaker was knowledgeable about the subject matter. 1 - Strongly Disagree 2 - Somewhat Disagree 3 - Unsure 4 - Mostly Agree 5 - Strongly Agree The audio recording was of good quality and easy to hear. 1 - Strongly Disagree 2 - Somewhat Disagree 3 - Unsure 4 - Mostly Agree 5 - Strongly Agree The video recording was of good quality and easy to see. 1 - Strongly Disagree 2 - Somewhat Disagree 3 - Unsure 4 - Mostly Agree 5 - Strongly Agree The written material was easy to follow with the recording. 1 - Strongly Disagree 2 - Somewhat Disagree 3 - Unsure 4 - Mostly Agree 5 - Strongly Agree This seminar was consistent with advertised content. 1 - Strongly Disagree 2 - Somewhat Disagree 3 - Unsure 4 - Mostly Agree 5 - Strongly Agree The speaker was open about his/her financial and non-financial relationships; there was no apparent conflict of interest. 1 - Strongly Disagree 2 - Somewhat Disagree 3 - Unsure 4 - Mostly Agree 5 - Strongly Agree My overall experience with this seminar was positive. 1 - Strongly Disagree 2 - Somewhat Disagree 3 - Unsure 4 - Mostly Agree 5 - Strongly Agree I will be interested in additional recorded seminars from this speaker and company. Is there anything that you especially liked or disliked about this recorded seminar? Did you learn anything that you found exciting, new, or surprising? If so, will you tell us about it? Did you find anything challenging about the learning experience? If so, how could we have made it easier? Please use the space provided below to make comments on any of the items above or on any other aspect of your experience that you would like to bring to our attention.