Audiology Assistant Supervision Change

"*" indicates required fields

Step 1 of 8

12%

Cost: $20 (+$3 for PayPal)

Signature*

This form may only be completed by the Board licensed Audiologist registering this applicant under their audiology license. This form may not be completed by another Audiologist, Audiology Assistant, or Office Staff. By signing I certify that I, the potential supervising Audiologist for this registrant is completing this form as required by Article 22.

Audiology Assistant Registration Number*

Supervisor Information

Primary Supervisor*

Prefix First Middle Last

NC License Number*

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

Do you have a secondary supervisor?*

Yes

Secondary Supervisor's Name*

Prefix First Middle Last

Secondary Supervisor NC License Number*

Assistant Information

Audiology Assistant Name*

Prefix First Middle Last

Audiology Assistant Mailing Address*

Street Address Address Line 2 City State ZIP Code

Primary/Mobile Phone*

Work Phone

Audiology Assistant Email*

Enter Email Confirm Email

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.

Street Address Address Line 2 City State ZIP Code

Are there multiple locations where services will be provided?*

Yes

Additional Locations*

If services are being provided in homes, please provide the city and/or county in which the homes are located. For those cases please state they are, "home locations in City/County".

To add rows use "+".

Pure Tone Audiometry

Will the Audiology Assistant conduct pure tone audiometry under your supervision? If so, please provide the date the Board approved certificate program such as Certified Occupational Hearing Conservationists (COHC) administered.*

Yes, we WILL SUBMIT the certification for this Assistant

No, the Assistant will NOT conduct Pure Tone Audiometry

Exam Date

Pleas enter the date the exam was administered. If the Registrant takes and passes this after the registration is issued, please contact the Board to submit this information.

Month

Day

Year

Pure Tone Audiometry Certification*

Please attach the Pure Tone Audiometry certification for this Assistant.

Max. file size: 50 MB.

Assistant Protocol Target Behavior Form and Letter of Certification of Assistant's competency

Attach Protocol Target Behavior Form and Letter of Certification of the Assistant's competency*

Please attach the protocol form that will be used with your Audiology Assistant and Certification letter. Please refer to 21 NCAC 64 .1102 for specific requirements for these items.

Drop files here or

Max. file size: 50 MB.

Quiz

How many Audiology Assistants may be supervised by a licensee employed full time?*

Who must sign every patient encounter (screening or treatment) when services are provided by an Audiology Assistant?*

Primary Supervisor and Audiology Assistant

Audiology Assistant, Primary or Secondary supervisor

Primary Supervisor

Secondary Supervisor

An Audiology Assistant may perform unmasked pure-tone audiometry under general supervision by the licensee...*

As long as it is only for determining candidacy for a hearing device

For pediatric patients

For any adult patient as long as the supervisor approves

For adult patients if the assistant is COHC certified

Whose caseload does the Audiology Assistant serve?*

Primary Supervisor

Both the caseload of the Primary Supervisor and the Secondary Supervisor(s)

Any Audiologist

Anyone employed by the same facility

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

AUD-Assis.

Audiology Assistant

Hearing Assistant

Assistant

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

Primary Supervisor

Board of Examiners

Employer

Secondary Supervisor

Who has the full responsibility for the accuracy and compliance of the documentation of tasks performed by an Audiology Assistant?*

Any secondary supervising licensee

The Audiology Assistant

The Primary Supervising Licensee

The NCBOESLPA

Which of the following is not required of a licensee when services are being rendered to the public by an Audiology Assistant?*

The supervising licensee must be in the same building as the Audiology Assistant

The licensee must be accessible to the Assistant

The Audiology Assistant must wear a badge including the job title: "Audiology Assistant"

The Patient must be notified that they are being seen by an Audiology Assistant

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

Primary Supervising Licensee

Both the Primary Supervising Licensee and the Secondary Supervising Licensee

Audiology Assistant

The Office Administrator

Administrative staff in an audiology practice who perform indirect patient care like checking in hearing devices must now be registered as Audiology Assistants.*

False

True

Supervisor & Assistant Consent & Signatures

Click here to download Section 21 NCAC 64 .1101 - 1105 - Requirements for the use of Audiology Assistants in Direct Service Delivery in North Carolina.

To be completed by the Assistant

I have read Section 21 NCAC 64 .1101 - 1105 - 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 Supervisor

As supervisor of the above listed applicant, I have read the Licensure Act for Speech-Language Pathologists and Audiologists including the Requirements for the Use of 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 within 50 miles of the Assistant while he or she is providing services. I also certify that all information in this application is correct.

Signature of Supervisor*

Please print this file from the PDF that is emailed to you and have your supervisor sign here.

Date

Month

Day

Year

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 (for PDF delivery)*

Please enter an email address to receive a copy of this completed form.

Enter Email Confirm Email

Payment Information

Product Name

Payment Options*

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

Mail Payment with printed form

Total

Payment Method

American Express

Discover

MasterCard

Visa

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

Card Number Expiration Date Security Code Cardholder Name

Audiology Assistant Supervision Change Form

"*" indicates required fields

Step 1 of 8

12%

Cost: $20 (+$3 for PayPal)

Signature*

Audiology Assistant Registration Number*

Supervisor Information

Primary Supervisor*

Prefix First Middle Last

NC License Number*

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

Do you have a secondary supervisor?*

Yes

Secondary Supervisor's Name*

Prefix First Middle Last

Secondary Supervisor NC License Number*

Assistant Information

Audiology Assistant Name*

Prefix First Middle Last

Audiology Assistant Mailing Address*

Street Address Address Line 2 City State ZIP Code

Primary/Mobile Phone*

Work Phone

Audiology Assistant Email*

Enter Email Confirm Email

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.

Street Address Address Line 2 City State ZIP Code

Are there multiple locations where services will be provided?*

Yes

Additional Locations*

If services are being provided in homes, please provide the city and/or county in which the homes are located. For those cases please state they are, “home locations in City/County”.

To add rows use “+”.

Pure Tone Audiometry

Yes, we WILL SUBMIT the certification for this Assistant

No, the Assistant will NOT conduct Pure Tone Audiometry

Exam Date

Pleas enter the date the exam was administered. If the Registrant takes and passes this after the registration is issued, please contact the Board to submit this information.

Month

Day

Year

Pure Tone Audiometry Certification*

Please attach the Pure Tone Audiometry certification for this Assistant.

Max. file size: 50 MB.

Assistant Protocol Target Behavior Form and Letter of Certification of Assistant's competency

Attach Protocol Target Behavior Form and Letter of Certification of the Assistant's competency*

Please attach the protocol form that will be used with your Audiology Assistant and Certification letter. Please refer to 21 NCAC 64 .1102 for specific requirements for these items.

Drop files here or

Max. file size: 50 MB.

Quiz

How many Audiology Assistants may be supervised by a licensee employed full time?*

Who must sign every patient encounter (screening or treatment) when services are provided by an Audiology Assistant?*

Primary Supervisor and Audiology Assistant

Secondary Supervisor

Primary Supervisor

Audiology Assistant, Primary or Secondary supervisor

An Audiology Assistant may perform unmasked pure-tone audiometry under general supervision by the licensee…*

For pediatric patients

As long as it is only for determining candidacy for a hearing device

For adult patients if the assistant is COHC certified

For any adult patient as long as the supervisor approves

Whose caseload does the Audiology Assistant serve?*

Anyone employed by the same facility

Both the caseload of the Primary Supervisor and the Secondary Supervisor(s)

Primary Supervisor

Any Audiologist

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

Audiology Assistant

AUD-Assis.

Assistant

Hearing Assistant

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

Employer

Secondary Supervisor

Primary Supervisor

Board of Examiners

Who has the full responsibility for the accuracy and compliance of the documentation of tasks performed by an Audiology Assistant?*

The Primary Supervising Licensee

The Audiology Assistant

Any secondary supervising licensee

The NCBOESLPA

Which of the following is not required of a licensee when services are being rendered to the public by an Audiology Assistant?*

The licensee must be accessible to the Assistant

The Patient must be notified that they are being seen by an Audiology Assistant

The supervising licensee must be in the same building as the Audiology Assistant

The Audiology Assistant must wear a badge including the job title: “Audiology Assistant”

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

Audiology Assistant

The Office Administrator

Administrative staff in an audiology practice who perform indirect patient care like checking in hearing devices must now be registered as Audiology Assistants.*

False

True

Supervisor & Assistant Consent & Signatures

Click here to download Section 21 NCAC 64 .1101 – 1105 – Requirements for the use of Audiology Assistants in Direct Service Delivery in North Carolina.

To be completed by the Assistant

I have read Section 21 NCAC 64 .1101 – 1105 – 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 Supervisor

Signature of Supervisor*

Please print this file from the PDF that is emailed to you and have your supervisor sign here.

Date

Month

Day

Year

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 (for PDF delivery)*

Please enter an email address to receive a copy of this completed form.

Enter Email Confirm Email

Payment Information

Product Name

Payment Options*

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

Mail Payment with printed form

Total

Payment Method

American Express

Discover

MasterCard

Visa

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

Card Number Expiration Date Security Code Cardholder Name

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

Cost: $20 (+$3 for PayPal)

Supervisor Information

Assistant Information

Employer Information

Pure Tone Audiometry

Assistant Protocol Target Behavior Form and Letter of Certification of Assistant's competency

Quiz

Supervisor & Assistant Consent & Signatures

To be completed by the Assistant

To be completed by the Supervisor

Notice

Payment Information

Audiology Assistant Supervision Change Form

Cost: $20 (+$3 for PayPal)

Supervisor Information

Assistant Information

Employer Information

Pure Tone Audiometry

Assistant Protocol Target Behavior Form and Letter of Certification of Assistant's competency

Quiz

Supervisor & Assistant Consent & Signatures

To be completed by the Assistant

To be completed by the Supervisor

Notice

Payment Information

Assistants