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Audiology Assistants Registration
Step 1 of 3
33%
Cost: $40
Supervisor Information
Primary Supervisor
*
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
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
Mr.
Mrs.
Miss
Ms.
Dr.
First
Middle
Last
NC License Number
*
Assistant Information
Name
*
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
First
Middle
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Service Locations
*
Provide the exact location where the Assistant will provide services.
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.
Please select the date the exam was administered.
Date Format: MM slash DD slash YYYY
AUD Exam Score
Assistant Protocol Target Behavior Form
Attach Protocol Target Behavior Form
Please attach the protocol form that will be used with your Audiology Assistant.
Quiz
Who is completely responsible for the services provided by the registered Audiology Assistant?
*
Secondary Supervisor
Primary Supervisor
Board of Examiners
Employer
Whose caseload does the Audiology Assistant serve?
*
Secondary Supervisor employed by the same facility
Any audiologist
Both the caseload of the Primary Supervisor and the Secondary Supervisor
Primary Supervisor
How many Audiology Assistants may be supervised by a licensee employed full time?
*
1
2
3
4
Who is responsible for keeping the Board of Examiners apprised of changes in registration information?
*
The Office Administrator
Primary Supervising Licensee
Audiology Assistant
Both the Primary Supervising Licensee and the Secondary Supervising Licensee
What is the correct designator to be used by the Audiology Assistant on all documents?
*
AUD-Assis.
Hearing Assistant
Assistant
Audiology Assistant
Which of the following is not required of a licensee when services are being rendered to the public by an Audiology 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”
The licensee must be accessible to the Assistant
Who must sign every patient encounter (screening or treatment) when services are provided by an Audiology Assistant?
*
Secondary Supervisor
Primary Supervisor
Audiology Assistant, Primary or Secondary supervisor
Primary Supervisor and Audiology Assistant
Administrative staff in an audiology practice who perform indirect patient care like checking in hearing devices must now be registered as Audiology Assistants.
*
True
False
An Audiology Assistant may perform unmasked pure-tone audiometry under general supervision by the licensee
*
For adult patient if the assistant is COHC certified
As long as it is only for determining candidacy for a hearing device
For any adult patient as long as the supervisor approves
For pediatric patients
Who has the full responsibility for the accuracy and compliance of the documentation of tasks performed by an Audiology Assistant?
*
The NCBOESLPA
The Audiology Assistant
Any secondary supervising licensee
The primary supervising licensee
Email print version of completed form
Would you like a PDF version of this completed form emailed to you?
*
Yes
No
Email (for PDF delivery)
*
Please enter an email address to receive a copy of this completed form.
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
Date Format: MM slash DD slash YYYY
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.
Notice
Any change in the above plan OR supervisor must be reported to the Board PRIOR to implementing the change or continuing the practice.
Payment
Upon submission of this form you will be redirected to PayPal to pay your $40 fee + $2 PayPal transaction fee.
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