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Click Here for more Information
SLP-Assistant Supervision Changes
Step 1 of 5
20%
Cost: $20
Assistant Information
Name
*
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
First
Middle
Last
Registration Number
*
Address
*
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
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Maine
Maryland
Massachusetts
Michigan
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Mississippi
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New York
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Ohio
Oklahoma
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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
Home Phone
*
Work Phone
*
Reason for Change
*
SLP-Assistant will no longer work under previous supervisor
This is additional employment. SLP-A will continue to work under previous Primary Supervisor as well.
Preferred Start Date (must be a future date)
Date Format: MM slash DD slash YYYY
SLP-Assistant’s hours per week under this supervision
*
Primary Supervisor Information
Primary Supervisor
*
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
First
Middle
Last
NC License Number
*
Number of other SLP-Assistants the Primary Supervisor is the primary supervisor for.
*
This # is not including this SLP-Assistant.
Number of hours the Primary Supervisor works per week.
*
Secondary Supervisor Information
Secondary Supervisor
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
First
Middle
Last
NC License Number
Number of other SLP-Assistants the Secondary Supervisor is the secodary supervisor for.
This # is not including this SLP-Assistant.
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 SLP-A will provide services. If in homes, list the areas such as towns or counties of the homes. Daycare names and addresses are required.
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.
Quiz
Knowledge Demonstration for Licensed Speech Language Pathologists to Register a SLP-Assistant
Who is completely responsible for the services provided by the registered SLP-Assistant?
*
Secondary Supervisor
Primary Supervisor
Employer
Board of Examinations
Whose caseload does the SLP-Assistant serve?
*
Any SLP who is employed at the same facility
Primary Supervisor
Secondary Supervisor
Both the caseload of the Primary Supervisor and Secondary Supervisor
What is included in a written session plan (treatment protocol)?
*
the eliciting condition
the target behavior(s)
the consequences of target behavior(s)
All of the above
For how many Speech-Language Pathology Assistants may a licensed SLP who works full-time serve as the Primary Supervisor?
*
1
2
3
4
Who is responsible for keeping the Board of Examiners apprised of changes in registration information?
*
Primary Supervising Licensee
Both the Primary Supervising Licensee and the Secondary Supervising Licensee
SLP-Assistant
SLP-Assistant
What is the correct designator to be used by the SLP-Assistant on all documents?
*
Assistant
SLP-A
SLP-Assistant
Speech-Language Pathology Assistant
Which of the following is NOT required of a licensee when services are being rendered to the public by a SLP-Assistant?
*
The supervising licensee must be in the same building as the SLP-Assistant
The SLP-Assistant must wear a badge including the job title: "Speech-Language Pathology Assistant"
The licensee must be accessible to the Assistant
The Patient or family must be informed in writing
Who must sign every patient encounter (screening or treatment) when services are provided by a SLP-Assistant?
*
Secondary Supervisor
Primary Supervisor
Primary Supervisor and SLP-Assistant
SLP-Assistant
Which is NOT a required element of a session protocol?
*
The protocol must be signed by the patient or guardian
The protocol must be signed by the SLP-Assistant and the supervising licensee
The protocol must be in writing
The protocol must specify the eliciting conditions, the target behavior, and the contingent response.
The written treatment protocol must include all EXCEPT:
*
Specification of the contingent response to the patient's behavior
Specification of how the target behavior is to be elicited
Specifications of how data is to be collected
Specification of the target behavior
SLP-Assistant Protocol Target Behavior Form
Attach completed SLP-Assistant Protocol Target Behavior Form THIS HAS TO BE SIGNED
*
Download form here
to be completed and submitted with this application.
Performance-Based Competency Assessment & Orientation Checklist for SLP-Assistants
Download form here
to be completed and submitted within 90 days from the date of registration or supervision change.
Requirements for registering a SLP-Assistant
*
I have read and understand the
Requirements for Registering a SLP-Assistant
I have.
Supervisor & Assistant Consent & Signatures
Click here to download Section .1000-.1005 - Requirements for the Use of Speech-Language Pathology Assistants in Direct Service Delivery in North Carolina
To be completed by the SLP-Assistant
I have read Section .1000-.1005 – of Article 22 – Licensure Act for Speech-Language Pathologists - Requirements for the Use of Speech-Language Assistants in Direct Service Delivery in North Carolina and Audiologists, and I agree to abide by all of its requirements. I also certify that all information provided in this application is correct.
Signature of Applicant
*
Date
Date Format: MM slash DD slash YYYY
To be completed by the Primary Supervisor
As supervisor of the above listed applicant, I have read Section .1000-.1005 – of Article 22 – Licensure Act for Speech-Language Pathologists - Requirements for the Use of Speech-Language Assistants in Direct Service Delivery in North Carolina and Audiologists, 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 SLP-Assistant. I understand that I or the above named Secondary Supervisor if one is listed, must be within 50 miles of the SLP-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.
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.
SLP-Assistant Supervision Changes Fee
Convenience Fee
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