Audiology Assistants Registration

Cost: $40
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.
Please select the date the exam was administered.
Date Format: MM slash DD slash YYYY
AUD Exam Score

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Assistant Protocol Target Behavior Form
Attach Protocol Target Behavior Form
Please attach the protocol form that will be used with your Audiology Assistant.

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Supervisor Information

Training Program	Major	Degree	Date