Audiology Assistants Registration

Cost: $40

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, AUD.-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.

Supervisor Information

Primary Supervisor*

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.

Do you have a secondary supervisor?*

Yes
No

Secondary Supervisor*

Prefix First Middle Last

NC License Number*

Assistant Information

Name*

Prefix First Middle Last

Address*

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

Home Phone*

Work Phone

Email

Social Security Number*

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
No

Additional Locations*

Please list any additional locations where services will be provided.

Academic Information

Academics*

Training Program	Major	Degree	Date

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
NO

Exam Date

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

Guidance for OTC Hearing Aids View Resources

Step 1 of 3

Cost: $40

Supervisor Information

Assistant Information

Employer Information

Academic Information

Assistant Protocol Target Behavior Form

Quiz

Supervisor & Assistant Consent & Signatures

To be completed by the Assistant

To be completed by the Supervisor

Notice

Payment Information