SEY Plan

NOTICE TO APPLICANTS FOR TEMPORARY LICENSE

The Board of Examiners for Speech and Language Pathologists and Audiologists has determined that supervised experience which will meet the Board’s approval for a permanent license must be characterized by a least seventy percent (70%) of work time devoted to clinical activities (e.g. planning for direct patient services, analysis of data obtained in diagnostic and/or therapeutic services, analysis of data obtained in diagnostic and/or therapeutic contacts, reporting and/or counseling with patients and their families or other professionals). Not to be included in meeting the 70% requirement are journal groups, administrative activities, staff meetings, inservice training, public relations, or travel.

IT IS THE RESPONSIBILITY OF THE APPLICANT OR TEMPORARY LICENSEE TO NOTIFY THEIR IMMEDIATE SUPERIOR AND EMPLOYER, IF DIFFERENT, OF THIS REQUIREMENT. IF THERE IS TO BE ANY CHANGE OF ANY KIND ON THE SUPERVISED EXPERIENCE YEAR PLAN THAT WAS APPROVED, A NEW SEY PLAN MUST BE PROVIDED TO THE BOARD BEFORE THE CHANGE IS MADE.

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License Application Area*
- Speech-Language Pathology
- Audiology
Plan Options*
- This is my first plan
- This is to replace my current plan
- This is additional employment
Identification
Name*
Prefix First Middle Last
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Home or Personal Phone
Business Address*
Please enter your Employer's address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Phone*
Please enter your Employer's phone number
Preferred Mailing Address*
- Home
- Business

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Supervised Experience Setting
Service Locations
Will you be providing services at more than one location?
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Service Locations: Temporary Applicant*
I understand that by listing additional locations they will be listed in North Carolina only. The Board has jurisdiction over NC locations. If I list locations that are not in NC the plan won't be approved.

If I'm providing services in other states I understand that I will have to maintain compliance with NC rules and regulations. To do this, I will reach out to the state(s) speech and audiology licensure boards and follow their rules and regulations for providing services to patients in their state.
I understand

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Exact names/addresses of places of supervised experience (Work Sites)*
Note: If providing services in homes, please list the smallest area in which the visits will take place. For example, the town of Liberty, NC. You must provide names and addresses of all daycares, schools and all facilities. You may add as many lines as you need. The Board has jurisdiction over NC locations. If locations that are not in NC are listed the plan cannot be approved.
Preferred Start Date for This Plan*
If this is a supervision change, enter the date that you would like the change to become effective. No changes should take place until you have received confirmation from the Board that the changes have been approved.
Month
Day
Year
Are you working in the school system / not planning to work during the summer?*
- Yes
- No
Last day of school for this year*
Month
Day
Year
First day of school for next school year*
Month
Day
Year
Supervisor
Name of Supervisor*
Prefix First Middle Last
N.C. License #*
Employer's Name*
Employer's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer's Phone*

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To be completed by the Applicant
If your supervisor needs to sign the form and is not present to sign this form, the PDF file that is emailed may be printed, signed, then submitted.
Signature of Applicant*
I have met with and discussed this plan with my SEY supervisor. Furthermore, I checked and found that my supervisor holds a valid N.C. license in the area in which I seek licensure. If it is determined at a later date that this statement is not true, I and not the Board, assume full responsibility for a invalid SEY. I also understand that my SEY Plan will be denied.
Date
Month
Day
Year
To be completed by the Supervisor
If your supervisor needs to sign the form and is not present to sign the form, the PDF file that is emailed may be printed, signed, then submitted.
Signature of Supervisor*
I have met with and discussed this plan with the applicant and accept responsibility for its implementation. Furthermore, I certify that my license will be current throughout this SEY and I will fulfill this responsibility even if I am unable to recommend the applicant at the end of the SEY experience. I understand that by signing off on this SEY Plan that I am certifying that I hold a valid NC license. I understand that if I do not hold a valid NC license I will be in violation of Section § 90-294 (B).
Notice
Any change in the above plan OR supervisor must be reported to the Board PRIOR to implementing the change or continuing the practice.
Email Completed Form
If both signatures are present on the form, then you do not need to do anything further with the electronic form submission. If both signatures are not present on the form submission send the PDF to your supervisor for their signature, then return via email to Executive Director Denise Brown. If emailing to Ms. Brown be sure to CC the other individual who is named on the form.
Email (for PDF delivery)*
Please enter an email address to receive a copy of this completed form.

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Guidance for OTC Hearing Aids View Resources

SEY Plan

Step 1 of 10

NOTICE TO APPLICANTS FOR TEMPORARY LICENSE

Identification

Supervised Experience Setting

Supervisor

Clinical and Supervisory Responsibilities

To be completed by the Applicant

To be completed by the Supervisor

Notice

Email Completed Form