SLP-Assistant Supervision Change 2.0

"*" indicates required fields

Cost: $20 (+$3 for PayPal)

This form may only be completed by the slp requesting the below listed slp-assistant be added to their license. This form may not be completed by another slp, slp-assistant, or office staff.*

By signing I certify that I, the potential supervising licensee for this registrant, is completing this form as required by Article 22.

Assistant Information

Assistant Name*

Prefix First Middle Last

Registration Number*

0 of 4 max characters

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Primary/Mobile Number*

Work Number*

SLP-Assistant's Email*

Enter Email Confirm Email

Reason for Change*

If your potential assistant is in suspended status, and has been registered with the Board before be sure to use the SLP-Assistant registration form.

If your potential assistant is in the suspended status and is a temporary SLP-Assistant the temporary SLP-Assistant registration form should be used.

To prevent delay, you should not continue filling out this form if one of the above applies.

This is additional employment. Assistant will continue to work under previous Primary Supervisor at another location.

Assistant will no longer work under previous supervisor, and the previous supervisor has/will notify the Board that this SLP-Assistant should be removed from their license with this effective supervision change (IF THEY ARE STILL UNDER ANOTHER SLP IT CAN DELAY THE PROCESSING TIME.)

Preferred Start Date (must be a future date)

Please allow up to ten days for processing once we received all requirements for the requested change. This request does not constitute approval of supervision change. You must verify the change in your license portal, or on the Board's website before the SLP-Assistant may begin providing services under your license.

Month

Day

Year

Assistant's hours per week under this supervision*

New Primary Supervisor Information

This information should match the signature provided at the beginning of this form. This form may only be completed by the slp requesting the above listed slp-assistant be added to their license. This form may not be completed by another slp, slp-assistant, or office staff.

Name*

Prefix First Middle Last

Primary Supervisor's Email*

This email should match the email used in the "Email (for PDF delivery)" field at the end of the form before payment is completed.

Enter Email Confirm Email

NC License Number*

0 of 8 max characters

Number of other Assistants the Primary Supervisor currently has.*

This number is not including this Assistant, and includes slp-assistants in other states if applicable

Number of hours the Primary Supervisor works per week.*

Do you have a secondary supervisor?*

Yes

Secondary Supervisor's Name*

Prefix First Middle Last

Secondary Supervisor NC License Number*

0 of 8 max characters

Employer Information

Employer Name*

Employer Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Service Locations*

Provide the exact location where the Assistant will provide services. If in homes, list the areas such as towns or counties of the homes and state it is for homes. Businesses, schools, Head Start Programs, and daycares require complete names and addresses.

An SLP-Assistant may not provide services under multiple SLPs at the same location or across multiple locations.

Street Address Address Line 2 City State ZIP Code

Additional Service Locations*

Are there multiple locations where services will be provided?

Yes

Additional Locations*

Please list any additional locations where services will be provided. Complete names and addresses are required for businesses, schools, Head Start Programs, and daycares.

To add rows use "+".

An SLP-Assistant may not provide services under multiple SLPs at the same location or across multiple locations.

Attestation 1*

I have read and understand that, as the primary supervising licensee I am responsible for all patient services provided by the slp-assistant registered on my license. I understand that I am not able to delegate this responsibility to anyone else (ex. another licensee within the same company/place of employment, secondary supervising licensee, office manager, etc.). Authority 21 NCAC 64 .1003 (e).

I understand

Attestation 2*

I have read and understand that, as the primary supervising licensee even when an evaluation has previously been completed I should personally evaluate/re-evaluate (the evaluation may be formal or informal) each patient on my caseload before assigning any treatment tasks to the slp-assistant registered on my license. For additional licensee requirements not listed above please read 21 NCAC 64 .1003. Authority 21 NCAC 64 .1003 (e)(1).

I understand

Attestation 3*

I have read and understand that, as the supervising licensee I am responsible for being aware of the authorized tasks of speech-language pathology assistants as outlined by 21 NCAC 64 .1004. I understand that, assigning tasks that fall outside of 21 NCAC 64 .1004 can result in possible violation of the statute and rules that govern speech-language pathology licensure in North Carolina. Authority G.S. 90-301A (8).

I understand

Attestation 4*

I have read and understand that, as the primary supervising licensee I am responsible for discussing job expectations and ensuring that there is mutual understanding of job scope and specific responsibilities. This includes and is not limited to, providing regular, formal employment evaluations on a scheduled basis to assess performance, strengths and weaknesses, and establish development goals for continuous performance improvement. For additional supervision and continuing competence requirements not listed above please read 21 NCAC 64 .1005. Authority 21 NCAC 64 .1005.

I understand

Primary Supervisors Signature*

I understand that if I do not pass the quiz my paperwork cannot be processed until the Board office receives a passing score.

Quiz

Knowledge demonstration for licensed speech-language pathologists to register an slp-assistant. TO BE COMPLETED BY THE ABOVE LISTED PRIMARY SUPERVISING SLP.

Which of the following is NOT required of a licensee when services are being rendered to the public by a SLP-Assistant?*

The supervising licensee must be in the same building as the SLP-Assistant

The SLP-Assistant must wear a badge including the job title: "Speech-Language Pathology Assistant"

The licensee must be accessible to the Assistant

The Patient or family must be informed in writing

The written treatment protocol must include all EXCEPT:*

Specification of the contingent response to the patient's behavior.

Specification of the target behavior.

Specifications of how data is to be collected.

Specification of how the target behavior is to be elicited.

Which is NOT a required element of a session protocol?*

The protocol must be signed by the slp-assistant and the supervising licensee.

The protocol must specify the eliciting conditions, the target behavior, and the contingent response.

The protocol must be in writing

The protocol must be signed by the patient or guardian.

Who must sign every patient encounter (screening or treatment) when services are provided by a SLP-Assistant?*

Secondary Supervisor

Primary Supervisor and SLP-Assistant

Primary Supervisor

SLP-Assistant

What is included in a written session plan (treatment protocol)?*

the eliciting condition

the consequences of target behavior(s)

All of the above

the target behavior(s)

For how many Speech-Language Pathology Assistants may a licensed SLP who works full-time serve as the Primary Supervisor?*

Whose caseload does the SLP-Assistant serve?*

Both the caseload of the Primary Supervisor and Secondary Supervisor

Any SLP who is employed at the same facility

Primary Supervisor

Secondary Supervisor

Who is responsible for keeping the Board of Examiners apprised of changes in registration information?*

Employer

SLP-Assistant

Primary Supervising Licensee

Both the Primary Supervising Licensee and the Secondary Supervising Licensee

What is the correct designator to be used by the SLP-Assistant on all documents?*

SLP-Assistant

SLPA

Primary Assistant

Assistant

Who is completely responsible for the services provided by the registered SLP-Assistant?*

Primary Supervisor

Employer

Board of Examinations

Secondary Supervisor

Assistant Protocol Target Behavior & Feeding and Swallowing Protocol Forms

Attach the completed SAMPLE slp-assistant protocol target behavior form this has to be signed and completed as it would be for a real patient/client*

Download the SLP-Assistant Protocol Target Behavior form, you must complete a sample of this form as your would for a real patient/client your SLP Assistant would be providing services for.

This is to show the Board you understand how to complete the form properly. Please attach the sample below.

Once the SLP Assistant is approved under your license this specific form is required to be completed by the Primary supervising SLP for EACH patient/client based on that clients specific needs/ goals that the SLP Assistant will be using to meet the goals with. Each patient/client's target behavior form will need to remain in their file until a new one is created based on the clients current status and goals .

The Primary SLP will need to evaluate the patient/client and fill out a target behavior form for that patient/client before the SLP Assistant begins providing services and using the target behavior form.

These forms are subject to Board audit at any time.

IF THE SAMPLE ATTACHED TO THIS REQUEST IS INCORRECT OR INCOMPLETE THE REGISTRATION WILL NOT BE ABLE TO BE APPROVED, AND YOU WILL BE REQUIRED TO RESUBMIT.

Max. file size: 50 MB.

Will this slp-assistant be providing feeding/swallowing services?*

Yes, I have attached a sample feeding/swallowing protocol form below.

Attach the completed applicable feeding/swallowing protocol form. This has to be signed.*

Download the SLP-Assistant Feeding/Swallowing Protocol form.This form is for SLP-Assistants who will be providing Feeding and/or Swallowing services within the Board's scope of practice for SLP Assistants.

THIS FORM IS NOT THE SAME AS THE TARGET BEHAVIOR FORM USED ABOVE.

Max. file size: 50 MB.

Performance-Based Competency Assessment & Orientation Checklist for SLP-Assistants

Download form here to be completed and submitted within 90 days from the date of registration or supervision change.

Requirements for completing the treatment protocol form*

I have read and understand the requirements for completing the treatment protocol form.

I have

Requirements for registering an assistant*

I have read and understand the Requirements for Registering an SLP-Assistant.

I have

Supervisor & Assistant Consent & Signatures

To be completed by the Assistant

I have read the applicable Section pertaining to the supervision requirements for the Assistant I will be supervising (Section .1000-.1005 of Article 22 Licensure Act for Speech-Language Pathologists and Audiologists Requirements for the Use of Speech-Language Assistants in Direct Service Delivery in North Carolina, or Section .1101-.1005 Requirements for the Use of Audiology Assistants in Direct Service Delivery in North Carolina), and I agree to abide by all of its requirements. I also certify that all information provided in this application is correct.

Signature of Assistant*

Date*

Month

Day

Year

To be completed by the Primary Supervisor

As supervisor of the above listed applicant, I have read the applicable Section pertaining to the supervision requirements for the Assistant I will be supervising (Section .1000-.1005 – of Article 22 – Licensure Act for Speech-Language Pathologists - Requirements for the Use of Speech-Language Assistants in Direct Service Delivery in North Carolina or Section .1101-.1005 Requirements for the Use of Audiology Assistants in Direct Service Delivery in North Carolina) and I agree to abide by all of its requirements. I understand that as the supervisor, I accept responsibility for the professional services carried out by this Assistant. I understand that I or the above named Secondary Supervisor if one is listed, must be available to the Assistant while they are providing services. I also certify that all information in this application is correct.

Signature of Supervisor*

Date*

Month

Day

Year

Email (for PDF delivery)*

Please enter the Primary Supervising licensees email address to receive a copy of this completed for. This should match the email provided under "Primary Supervisor's Email" towards the beginning of this form.

Enter Email Confirm Email

Payment Information

Upon Submission

Once the Board receives the completed paperwork and fee please allow up to 10 days for processing. To avoid processing delays, updates will not be provided in the duration of the 10 days. Once the request is approved you will receive and email confirming the change, your portal and the website will also reflect the change when it is processed.

Assistant Supervision Change

Payment Options

PayPal (A $3 fee will be added for online payments)

Mail payment with printed form

Mail payment with printed form*

I understand that if I choose to mail in payment with printed form the Board office will not receive my form submission. I understand that the most common reason for delay is error in completing the form correctly, providing the required information, and not following the instructions. Error can be avoided if you proceed through this form submission carefully, thoroughly, and accurately. If you have any questions or need assistance, call the Board of Examiners at 336-272-1828.

I understand

Payment Method

American Express

Discover

MasterCard

Visa

Maestro

Supported Credit Cards: American Express, Discover, MasterCard, Visa, Maestro

Card Number Expiration Date Security Code Cardholder Name

Total

Assistant Supervision Changes 2.0

"*" indicates required fields

Cost: $20 (+$3 for PayPal)

This form may only be completed by the slp requesting the below listed slp-assistant be added to their license. This form may not be completed by another slp, slp-assistant, or office staff.*

By signing I certify that I, the potential supervising licensee for this registrant, is completing this form as required by Article 22.

Assistant Information

Assistant Name*

Prefix First Middle Last

Registration Number*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Primary/Mobile Number*

Work Number*

SLP-Assistant's Email*

Enter Email Confirm Email

Reason for Change*

If your potential assistant is in suspended status, and has been registered with the Board before be sure to use the SLP-Assistant registration form.

If your potential assistant is in the suspended status and is a temporary SLP-Assistant the temporary SLP-Assistant registration form should be used.

To prevent delay, you should not continue filling out this form if one of the above applies.

This is additional employment. Assistant will continue to work under previous Primary Supervisor at another location.

Preferred Start Date (must be a future date)

Please allow up to ten days for processing once we received all requirements for the requested change. This request does not constitute approval of supervision change. You must verify the change in your license portal, or on the Board’s website before the SLP-Assistant may begin providing services under your license.

Month

Day

Year

Assistant's hours per week under this supervision*

New Primary Supervisor Information

Name*

Prefix First Middle Last

Primary Supervisor's Email*

This email should match the email used in the “Email (for PDF delivery)” field at the end of the form before payment is completed.

Enter Email Confirm Email

NC License Number*

Number of other Assistants the Primary Supervisor currently has.*

This number is not including this Assistant, and includes slp-assistants in other states if applicable

Number of hours the Primary Supervisor works per week.*

Do you have a secondary supervisor?*

Yes

Secondary Supervisor's Name*

Prefix First Middle Last

Secondary Supervisor NC License Number*

Employer Information

Employer Name*

Employer Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Service Locations*

An SLP-Assistant may not provide services under multiple SLPs at the same location or across multiple locations.

Street Address Address Line 2 City State ZIP Code

Additional Service Locations*

Are there multiple locations where services will be provided?

Yes

Additional Locations*

Please list any additional locations where services will be provided. Complete names and addresses are required for businesses, schools, Head Start Programs, and daycares.

To add rows use “+”.

An SLP-Assistant may not provide services under multiple SLPs at the same location or across multiple locations.

Attestation 1*

I understand

Attestation 2*

I understand

Attestation 3*

I understand

Attestation 4*

I understand

Primary Supervisors Signature*

I understand that if I do not pass the quiz my paperwork cannot be processed until the Board office receives a passing score.

Quiz

Knowledge demonstration for licensed speech-language pathologists to register an slp-assistant. TO BE COMPLETED BY THE ABOVE LISTED PRIMARY SUPERVISING SLP.

Which of the following is NOT required of a licensee when services are being rendered to the public by a SLP-Assistant?*

The licensee must be accessible to the Assistant

The supervising licensee must be in the same building as the SLP-Assistant

The SLP-Assistant must wear a badge including the job title: “Speech-Language Pathology Assistant”

The Patient or family must be informed in writing

The written treatment protocol must include all EXCEPT:*

Specification of how the target behavior is to be elicited.

Specification of the contingent response to the patient’s behavior.

Specification of the target behavior.

Specifications of how data is to be collected.

Which is NOT a required element of a session protocol?*

The protocol must be in writing

The protocol must be signed by the patient or guardian.

The protocol must be signed by the slp-assistant and the supervising licensee.

The protocol must specify the eliciting conditions, the target behavior, and the contingent response.

Who must sign every patient encounter (screening or treatment) when services are provided by a SLP-Assistant?*

Primary Supervisor

Primary Supervisor and SLP-Assistant

SLP-Assistant

Secondary Supervisor

What is included in a written session plan (treatment protocol)?*

the consequences of target behavior(s)

the target behavior(s)

All of the above

the eliciting condition

For how many Speech-Language Pathology Assistants may a licensed SLP who works full-time serve as the Primary Supervisor?*

Whose caseload does the SLP-Assistant serve?*

Both the caseload of the Primary Supervisor and Secondary Supervisor

Secondary Supervisor

Any SLP who is employed at the same facility

Primary Supervisor

Who is responsible for keeping the Board of Examiners apprised of changes in registration information?*

Both the Primary Supervising Licensee and the Secondary Supervising Licensee

Primary Supervising Licensee

SLP-Assistant

Employer

What is the correct designator to be used by the SLP-Assistant on all documents?*

SLPA

Primary Assistant

Assistant

SLP-Assistant

Who is completely responsible for the services provided by the registered SLP-Assistant?*

Employer

Board of Examinations

Primary Supervisor

Secondary Supervisor

Assistant Protocol Target Behavior & Feeding and Swallowing Protocol Forms

Attach the completed SAMPLE slp-assistant protocol target behavior form this has to be signed and completed as it would be for a real patient/client*

Download the SLP-Assistant Protocol Target Behavior form, you must complete a sample of this form as your would for a real patient/client your SLP Assistant would be providing services for.

This is to show the Board you understand how to complete the form properly. Please attach the sample below.

Once the SLP Assistant is approved under your license this specific form is required to be completed by the Primary supervising SLP for EACH patient/client based on that clients specific needs/ goals that the SLP Assistant will be using to meet the goals with. Each patient/client’s target behavior form will need to remain in their file until a new one is created based on the clients current status and goals .

These forms are subject to Board audit at any time.

IF THE SAMPLE ATTACHED TO THIS REQUEST IS INCORRECT OR INCOMPLETE THE REGISTRATION WILL NOT BE ABLE TO BE APPROVED, AND YOU WILL BE REQUIRED TO RESUBMIT.

Max. file size: 50 MB.

Will this slp-assistant be providing feeding/swallowing services?*

Yes, I have attached a sample feeding/swallowing protocol form below.

Attach the completed applicable feeding/swallowing protocol form. This has to be signed.*

Download the SLP-Assistant Feeding/Swallowing Protocol form.This form is for SLP-Assistants who will be providing Feeding and/or Swallowing services within the Board’s scope of practice for SLP Assistants.

THIS FORM IS NOT THE SAME AS THE TARGET BEHAVIOR FORM USED ABOVE.

Max. file size: 50 MB.

Performance-Based Competency Assessment & Orientation Checklist for SLP-Assistants

Download form here to be completed and submitted within 90 days from the date of registration or supervision change.

Requirements for completing the treatment protocol form*

I have read and understand the requirements for completing the treatment protocol form.

I have

Requirements for registering an assistant*

I have read and understand the Requirements for Registering an SLP-Assistant.

I have

Supervisor & Assistant Consent & Signatures

To be completed by the Assistant

Signature of Assistant*

Date*

Month

Day

Year

To be completed by the Primary Supervisor

As supervisor of the above listed applicant, I have read the applicable Section pertaining to the supervision requirements for the Assistant I will be supervising (Section .1000-.1005 – of Article 22 – Licensure Act for Speech-Language Pathologists – Requirements for the Use of Speech-Language Assistants in Direct Service Delivery in North Carolina or Section .1101-.1005 Requirements for the Use of Audiology Assistants in Direct Service Delivery in North Carolina) and I agree to abide by all of its requirements. I understand that as the supervisor, I accept responsibility for the professional services carried out by this Assistant. I understand that I or the above named Secondary Supervisor if one is listed, must be available to the Assistant while they are providing services. I also certify that all information in this application is correct.

Signature of Supervisor*

Date*

Month

Day

Year

Email (for PDF delivery)*

Please enter the Primary Supervising licensees email address to receive a copy of this completed for. This should match the email provided under “Primary Supervisor’s Email” towards the beginning of this form.

Enter Email Confirm Email

Payment Information

Upon Submission

Assistant Supervision Change

Payment Options

PayPal (A $3 fee will be added for online payments)

Mail payment with printed form

Mail payment with printed form*

I understand

Payment Method

American Express

Discover

MasterCard

Visa

Maestro

Supported Credit Cards: American Express, Discover, MasterCard, Visa, Maestro

Card Number Expiration Date Security Code Cardholder Name

Total

Assistants

Speech-Language Pathology Assistants
Audiology Assistants
Renew my Assistants Registration
SLP-Assistant Supervision Change
Audiology Assistant Supervision Change
Verifications to Professional Entities
SLP-Assistant Competency Checklist
Audiology Assistant Competency Checklist

OTC Hearing Aids and "Prescription" Hearing Aids Resource Page view page

Cost: $20 (+$3 for PayPal)

Assistant Information

New Primary Supervisor Information

Employer Information

Quiz

Assistant Protocol Target Behavior & Feeding and Swallowing Protocol Forms

Performance-Based Competency Assessment & Orientation Checklist for SLP-Assistants

Supervisor & Assistant Consent & Signatures

To be completed by the Assistant

To be completed by the Primary Supervisor

Payment Information

Upon Submission

Assistant Supervision Changes 2.0

Cost: $20 (+$3 for PayPal)

Assistant Information

New Primary Supervisor Information

Employer Information

Quiz

Assistant Protocol Target Behavior & Feeding and Swallowing Protocol Forms

Performance-Based Competency Assessment & Orientation Checklist for SLP-Assistants

Supervisor & Assistant Consent & Signatures

To be completed by the Assistant

To be completed by the Primary Supervisor

Payment Information

Upon Submission

Assistants