Speech-Language Pathology Assistant Registration 3.0

Cost: $40 (+$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 slp for this registrant is completing this form as required by article 22. If this form is not signed properly, it will be denied.

Has the assistant been registered with the NC Board of Examiners for Speech-Language Pathologists and Audiologists before?*

If the assistant has not been registered with the NC Board they will need to fill out the assistant application, and you should not continue filling out this form.

Yes

No, this is for a full registration

SLP-Assistant Registration Number*

If you have a temporary registration with the Board be sure to include TEMP in front of your eight digit number. If you are unsure of your registration number please use the Board’s lookup function, or contact the Board office at 336-272-1828. If this is the applicants initial registration please put 4 zeros in this field.

New Supervisor Information

Supervisor Consent and Signature

Click here to download Section .1000-.1005 – Requirements for the Use of Speech-Language Pathology Assistants in Direct Service Delivery in North Carolina.

To be completed by the Primary Supervisor

As supervisor of the below 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*

Name*

Prefix First Middle Last

NC License Number*

Primary Supervisor Email*

This email address will be used to send the primary supervisor instructions and a link to the required Performance-Based Competency Assessment & Orientation Checklist.

Enter Email Confirm Email

How many SLP-Assistants do you currently supervise?*

This should include all SLP-Assistant(s) that you supervise, including under other licenses/registrations you may hold in other jurisdictions. This also includes if you are the secondary supervisor for any SLP Assistant(s).

None

One

Two or more

× Warning! If you are a Primary Supervisor for two SLP-Assistants registered on your license you cannot register to be the Primary Supervisor for a third!

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.

Street Address Address Line 2 City State ZIP Code

Additional Service Locations*

Are there multiple locations where services will be provided?

Yes

No

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 “+”.

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.

No

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.

Assistant Information

Assistant Name*

Prefix First Middle Last

Assistant Mailing Address*

Street Address Address Line 2 City State ZIP Code

Primary/Mobile Phone*

Work Phone

SLP-Assistant Email Address*

Enter Email Confirm Email

Academic Information

List

Training Program

Major

Degree

Date

SLP-Assistant Exam Date

Please select the date the exam was passed by the applicant, if they have taken their exam.

Email (for PDF delivery)*

Please enter the primary supervisor’s email address listed above to receive a copy of this completed form.

Enter Email Confirm Email

Payment Information

Notice

Any change in the above plan OR supervisor must be reported to the Board PRIOR to implementing the change or continuing practice.

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 during the duration of the 10 days. Once the request is approved you will receive an email confirming the change. Also, your portal and the website will reflect the approved change.

SLP-Assistant Registration

Payment Options

PayPal (A convenience fee will be added for online payments)

Mail payment with printed form

Payment Method

American Express

Discover

MasterCard

Visa

Maestro

Card Number Expiration Date Security Code Cardholder Name

Total

Proposed Rule Change (NCBOESLPA) – Supervision of SLP-Assistants view announcement

Cost: $40 (+$3 for PayPal)

New Supervisor Information

Supervisor Consent and Signature

To be completed by the Primary Supervisor

Employer Information

Assistant Protocol Target Behavior & Feeding and Swallowing Protocol Forms

Quiz

Assistant Information

Academic Information

Payment Information

Notice

Upon Submission