SEY Plan

Step 1 of 4

25%

NOTICE TO APPLICANTS FOR TEMPORARY LICENSE

The Board of Examiners for Speech and Language Pathologists and Audiologists has determined that supervised experience which will meet the Board’s approval for a permanent license must be characterized by a least seventy percent (70%) of work time devoted to clinical activities (e.g. planning for direct patient services, analysis of data obtained in diagnostic and/or therapeutic services, analysis of data obtained in diagnostic and/or therapeutic contacts, reporting and/or counseling with patients and their families or other professionals). Not to be included in meeting the 70% requirement are journal groups, administrative activities, staff meetings, inservice training, public relations, or travel.

IT IS THE RESPONSIBILITY OF THE APPLICANT OR TEMPORARY LICENSEE TO NOTIFY THEIR IMMEDIATE SUPERIOR AND EMPLOYER, IF DIFFERENT, OF THIS REQUIREMENT. IF THERE IS TO BE ANY CHANGE OF ANY KIND ON THE SUPERVISED EXPERIENCE YEAR PLAN THAT WAS APPROVED, A NEW SEY PLAN MUST BE PROVIDED TO THE BOARD BEFORE THE CHANGE IS MADE.
License Application Area*
- Speech-Language Pathology
- Audiology
Identification
Name*
Prefix First Middle Last
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Home or Personal Phone
Business Address*
Please enter your Employer's address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Phone*
Please enter your Employer's phone number
Preferred Mailing Address*
- Home
- Business

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Supervised Experience Setting
Exact names/addresses of places of supervised experience (Work Sites)*
Note: If providing services in homes, please list the smallest area in which the visits will take place. For example, the town of Liberty, NC. You must provide names and addresses of all daycares, schools and all facilities. You may add as many lines as you need.
Preferred Start Date for This Plan*
If this is a supervision change, enter the date that you would like the change to become effective. No changes should take place until you have received confirmation from the Board that the changes have been approved.
Date Format: MM slash DD slash YYYY
Are you working in the school system / not planning to work during the summer?*
- Yes
- No
Last day of school for this year*
Date Format: MM slash DD slash YYYY
First day of school for next school year*
Date Format: MM slash DD slash YYYY
Supervisor
Name of Supervisor*
Prefix First Middle Last
N.C. License #*
Place of Employment*
Employer's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer's Phone*

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Clinical and Supervisory Responsibilities
The Board shall interpret Section 90-295(4) to mean the supervision which will be satisfactory to the Board must include four hours per month of direct, on-site observation of the applicant's direct work with patients, in addition to "other" methods of supervision (e.g. video/audio tape recording review, records review, staff meetings, telephone conferences/correspondence, etc.). THE APPLICANT MUST BE EMPLOYED A MINIMUM OF TWENTY HOURS PER WEEK TO MAINTAIN AN ACTIVE LICENSE.
Assessment, diagnosis and/or evaluations*
Hours per week to be spent by applicant Planned hours per month of direct on-site supervision/area
Screening*
Hours per week to be spent by applicant Planned hours per month of direct on-site supervision/area
Habilitation/rehabilitation/therapy/counseling*
Hours per week to be spent by applicant Planned hours per month of direct on-site supervision/area
Staff meetings*
Hours per week to be spent by applicant
Record keeping*
Hours per week to be spent by applicant
Other
Please specify in the field below.
Hours per week to be spent by applicant
Please specify other methods
TOTAL*
Hours per week to be spent by applicant Planned hours per month of direct on-site supervision/area
Number of "other" types of planned supervision activities per month:

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To be completed by the Applicant
I have met with and discussed this plan with my SEY supervisor. Furthermore, I checked and found that my supervisor holds a valid N.C. license in the area in which I seek licensure. If it is determined at a later date that this statement is not true, I and not the Board, assume full responsibility for a invalid SEY.
Signature of Applicant*
Date
Date Format: MM slash DD slash YYYY
To be completed by the Supervisor
I have met with and discussed this plan with the applicant and accept responsibility for its implementation. Furthermore, I certify that my license will be current throughout this SEY and I will fulfill this responsibility even if I am unable to recommend the applicant at the end of the SEY experience.
Signature of Supervisor*
Please print this file from the PDF that is emailed to you and have your supervisor sign here.
Notice
Any change in the above plan OR supervisor must be reported to the Board PRIOR to implementing the change or continuing the practice.
Mail print version of completed form
This form may be printed and mailed with signatures to:
N.C. Board of Examiners for SLP & AUD
PO Box 16885
Greensboro, NC 27416-0885
Email (for PDF delivery)*
Please enter an email address to receive a copy of this completed form.

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Please read all announcements to learn of current COVID-19 Accommodations. New Announcement Posted 3/23/2020 Regarding Proposed Emergency Rule

Step 1 of 4

NOTICE TO APPLICANTS FOR TEMPORARY LICENSE

Identification

Supervised Experience Setting

Supervisor

Clinical and Supervisory Responsibilities

To be completed by the Applicant

To be completed by the Supervisor

Notice

Mail print version of completed form

Licensure & Listing

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