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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Notice to Applicant*
I understand by continuing to fill out this SEY Plan that I am certifying that I have submitted my application. I also understand that if I submit a SEY Plan and no application the office will not hold onto it unless there is an application in the office.
To know if your application has been received by the Board office you can call 336-272-1828 or send an email to Denise Brown or Elisabeth Newman.
- I understand
Notice to Applicant: SEY Plan Start Date*
I understand that the Board issues licenses the next business day after the board meeting and I should not plan to work the next business day after the board meeting.
- I understand

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If you have NOT submitted an application do not continue any further until the office has received your application.

If the office does not have an application. We do not hold onto the plan.

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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

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To maintain an active license an applicant must have a minimum of twenty (20) hours of employment.
Applicant Employment Notice*
I understand that by submitting this SEY Plan I will be working a minimum of twenty (20) hours per week in NC with NC patients. I understand that if I’m not working a minimum of twenty (20) hours per week in NC with NC patients I can’t hold a valid temporary license in NC.
I agree and understand!
Applicant Employment Notice Signature*
I understand that by submitting this SEY Plan I will be working a minimum of twenty (20) hours per week in NC with NC patients. I understand that if I’m not working a minimum of twenty (20) hours per week in NC with NC patients I can’t hold a valid temporary license in NC.
Applicant Employment Notice Signature: 90-295(4)*
I understand that the Board shall interpret Section 90-295(4) to mean the supervision which will be satisfactory to the Board must include four (4) hours per month of direct, on-site observation of the applicant’s direct work with patients for full-time employment, in addition to “other” methods of supervision (e.g. video/audio tape recording review, records review, staff meetings, telephone conferences/correspondence, etc.). THE APPLICANT MUST BE EMPLOYED A MINIMUM OF TWENTY HOURS PER WEEK IN NC WITH NC PATIENTS TO MAINTAIN AN ACTIVE LICENSE.

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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: Temporary Applicant*
I understand that if I submit an SEY Plan with out-of-state address(es) I will have to do the following:

Submit an official letter of verification to the Board office verifying that I’m licensed in the state(s) where I intend to provide services. Electronic verifications are sent to [email protected].

Work a minimum of 20 hours in NC providing services to NC patients.

To get credit for the time completed in other state(s) I will submit the NC SEY Report form that has been filled out with my supervisor(s) in the other state(s).

I understand that if I don’t comply with the instructions above my SEY Plan can’t be approved because the Board only has jurisdiction in NC; not in other state(s) and I won’t qualify for NC licensure.
I understand
Signature*
I understand that this NC SEY Plan submission will only contain: NC Locations, and NC Hours completed at NC Locations serving NC patients. If hours are completed in other state(s) I will follow the instructions previously provided for receiving credit for time completed in other state(s).
Service Locations
Will you be providing services at more than one location?
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
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.

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× Warning! It will take 5-7 business days to process this submission. Don’t plan to start working the same day the plan is submitted!
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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Clinical and Supervisory Responsibilities
The Board shall interpret Section 90-295(4) to mean the supervision which will be satisfactory to the Board must include four (4) hours per month of direct, on-site observation of the applicant’s direct work with patients for full-time employment, in addition to “other” methods of supervision (e.g. video/audio tape recording review, records review, staff meetings, telephone conferences/correspondence, etc.). THE APPLICANT MUST BE EMPLOYED A MINIMUM OF TWENTY HOURS PER WEEK TO MAINTAIN AN ACTIVE LICENSE.
Assessment, diagnosis and/or evaluations*
Hours of employment per week for applicant Planned hours per month of direct on-site supervision/area
Planned hours/month of direct on-site supervision/area must comply with Section 90-295(4). The Board interprets this to mean the supervision which will be satisfactory to the Board must include four (4) hours per month of direct, on-site observation of the applicant’s direct work with patients for full-time employment, in addition to “other” methods of supervision (e.g. video/audio tape recording review, records review, staff meetings, telephone conferences/correspondence, etc.). For part-time employment to be satisfactory must include two (2) hours per month of direct, on-site observation of the applicant’s direct work with patients, in addition to “other” methods of supervision (e.g. video/audio tape recording review, records review, staff meetings, telephone conferences/correspondence, etc.). THE APPLICANT MUST BE EMPLOYED A MINIMUM OF TWENTY HOURS PER WEEK TO MAINTAIN AN ACTIVE LICENSE.
Screening*
Hours of employment per week for applicant Planned hours per month of direct on-site supervision/area
Habilitation/rehabilitation/therapy/counseling*
Hours of employment per week for applicant Planned hours per month of direct on-site supervision/area
Staff meetings*
Hours of employment per week for applicant
Record keeping*
Hours of employment per week for applicant
Other
Please specify in the field below.
Hours of employment per week for applicant
Please specify other methods
TOTAL*
Hours of employment per week for applicant Planned hours per month of direct on-site supervision/area
Number of "other" types of planned supervision activities per month:

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Notice to Applicants*
Please do not plan to start working the day after board meeting. The board issues licenses the week after board meeting. We cannot let you know if you have been approved or not the day after the board meeting. Due to the number of applicants phone calls and emails inquiring about approved applications slow us down. Our goal is to issue your license as expeditiously as possible. Thank you for being considerate of other applicants!
I have read this statement

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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, proceed to the bottom of this page, enter your supervisor’s email address, and select “Save and Continue later”. The form can then be completed and submitted by your supervisor.
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, proceed to the bottom of this page, enter your supervisor’s email address, and select “Save and Continue later”. The form can then be completed and submitted by your supervisor.
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).
Signature of Supervisor*
If an SEY Plan is submitted with out-of-state address(es) I will make sure that I’m maintaining compliance with that state(s) laws, rules, and regulations regarding the delivery of speech-language pathology, audiology, or both services in that state(s).
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 proceed to the bottom of this page, enter your supervisor’s email address, and select “Save and Continue later”. The form can then be completed and submitted by your supervisor.
Email (for PDF delivery)*
Please enter an email address to receive a copy of this completed form.

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ASLP-IC Rulemaking comment period now open

SEY Plan

Step 1 of 11

NOTICE TO APPLICANTS FOR TEMPORARY LICENSE

To maintain an active license an applicant must have a minimum of twenty (20) hours of employment.

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