Audiology Assistant Competency Checklist

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Supervisor Information

This may only be completed by the Board approved supervising Audiologist, this form may not be completed by another Audiologist, the Audiology Assistant, or Office Staff.

Primary Supervisor*

Prefix First Middle Last

NC License Number*

Assistant Information

Name*

Prefix First Middle Last

NC Registration Number*

Instructions

The primary supervising audiologist will complete this competency and orientation document during the first sixty (60) days of employment and forward the signed, original copy to the Board of Examiner’s (the Board) office within 30 days of completion. A new competency assessment and orientation must be completed whenever the licensee who registers the assistant changes.

Qualifications and Employment Overview

The audiology assistant has completed an approved course of study acceptable to the Board, is currently registered with the Board, and is in good standing as an audiology assistant.*

Meets standard

Does not meet standard

The audiology assistant has completed an employment orientation at all sites where audiology services will be delivered by the assistant.*

Meets standard

Does not meet standard

The audiology assistant knows and understands the approved rules for audiology assistants, specifically Administrative Code 21 NCAC 64 .1101 – Administrative Code 21 NCAC 64 .1105.*

Meets standard

Does not meet standard

The supervising audiologist has informed the Audiology Assistant of the overall scope of their duties and responsibilities in the specific employment context.*

Meets standard

Does not meet standard

Direct Services to Patients/Clients

The audiology assistant conducts themself in a courteous and appropriate manner in all communication and interaction with clients/patients, families, caregivers, and other staff*

Meets standard

Does not meet standard

The audiology assistant identifies themself as a audiology assistant when greeting client and/or family.*

Meets standard

Does not meet standard

The audiology assistant wears a name tag at all times which identifies themself as an assistant.*

Meets standard

Does not meet standard

The audiology assistant provides instructions and/or explanations of treatment to the patient/client which are clear and complete, and are appropriate for the patient/client’s developmental level, language use, communication disorder, and level of understanding.*

Meets standard

Does not meet standard

The audiology assistant has been instructed in the proper administration of the screening instruments/tests which will be used in the employment setting(s) and accurately administers these screening instruments, as prescribed by the supervising audiologist.*

Meets standard

Does not meet standard

The audiology assistant prepares treatment/screening materials before the beginning of each treatment/screening session, as directed by the supervising audiologist, assuring that such materials are appropriate to the patient/ client’s age, developmental level, culture, and communication disorder.*

Meets standard

Does not meet standard

The audiology assistant starts and ends treatment sessions on time and follows the written treatment protocol developed and prescribed by the supervising audiologist.*

Meets standard

Does not meet standard

Health and Safety Standard

The audiology assistant utilizes universal precautions and adheres to the infection control procedures and guidelines of the employer(s).*

Meets standard

Does not meet standard

The audiology assistant will use appropriate procedures for the physical management of patients/clients and any necessary injury prevention strategies consistent with the employer’s policies and with state regulation.*

Meets standard

Does not meet standard

Summary

Were there any unmet standards?*

Yes

Action plans for unmet standards

Signature of Audiology Assistant*

Registration Number*

Date*

Month

Day

Year

Signature of Primary Supervising Licensee*

License Number*

Date*

Month

Day

Year

Email print version of completed form

Would you like a PDF version of this completed form emailed to you?*

Yes

Email (for PDF delivery)*

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

2026 Proposed Rule Change – Supervision of SLP-Assistants view here