SEY Plan

NOTICE TO APPLICANTS FOR TEMPORARY LICENSE

The Board shall interpret Section 90-295(4) to mean the supervision which will be satisfactory to the Board must include an average of four hours per month of direct observation of the applicant’s direct work with patients for full-time employment and an average of 2 hours per month of the applicant’s direct work with patients for part-time employment ,(telesupervision is accepted as direct supervision). Direct supervision is in addition to “other” methods of supervision (e.g. video/audio tape recording review, records review, staff meetings, telephone conferences/correspondence, etc.). It is required that the supervisor provide a total of 36 hours of direct observation of the applicant’s direct work with patients spread out over the 1,260 hours of employment. The temporary licensee must work under their temporary license for a minimum of 9 months and obtain at least 1,260 work hours with at least seventy percent (70%) of their work hours devoted to clinical activities before applying for a permanent license.

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.

Notice: Temporary Licensee Applicant*

I understand by continuing to fill out this SEY Plan that I am certifying that I have submitted my application. I also understand that the office will not hold onto SEY Plans for individuals who have not submitted an application.

You may contact the Board’s office at 336-272-1828 or send an email to Denise Brown or Elisabeth Newman for information about the receipt of your application.

Notice: Temporary Licensee Applicant*

AS LONG AS YOU HOLD A TEMPORARY LICENSE WITH THIS BOARD YOU ARE TO RECEIVE DIRECT SUPERVISION FROM YOUR SUPERVISOR EVERY MONTH! MEETING THE BOARD’S MINIMUMS DOES NOT EXEMPT YOU FROM MONTHLY SUPERVISION!

Notice to Applicant: SEY Plan Start Date*

I understand that the Board does not begin issuing temporary licenses until after the monthly Board meeting and it can take up to 10 business days following the Board meeting for my license to be issued. I also understand that my license cannot be issued until all documents, including the SEY Plan, have been submitted to and received by the Board’s office.

I understand

If you have NOT submitted an application do not continue any further until the office has received your application.

If the office does not have an application. We do not hold onto the plan.

License Application Area*

Speech-Language Pathology

Audiology

Plan Options*

This is my first plan

This is to replace my current plan

This is additional employment

Temporary Licensee Applicant Employment Notice Signature: 90-295(4)*

The Board shall interpret Section 90-295(4) to mean the supervision which will be satisfactory to the Board must include an average of four hours per month of direct observation of the applicant’s direct work with patients for full-time employment and an average of 2 hours per month of the applicant’s direct work with patients for part-time employment ,(telesupervision is accepted as direct supervision). Direct supervision is in addition to “other” methods of supervision (e.g. video/audio tape recording review, records review, staff meetings, telephone conferences/correspondence, etc.). It is required that the supervisor provide a total of 36 hours of direct observation of the applicant’s direct work with patients spread out over the 1,260 hours of employment. The temporary licensee must work under their temporary license for a minimum of 9 months and obtain at least 1,260 work hours with at least seventy percent (70%) of their work hours devoted to clinical activities before applying for a permanent license.

Temporary Licensee Applicant Signature*

Note: You must complete 1,260 work hours before applying for your permanent NC license. You will have 18 months to complete the hours. The 18-month period of time will start on the date that your temporary license is issued. One extension may be requested in writing and approved on a case-by-case basis. If the period of supervision has not been completed within 24 months, you will be required to restart your SEY and the hours obtained will not be counted. At least seventy percent (70%) of your work hours must be 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). Hours not to be included in meeting the 70% requirement are journal groups, administrative activities, staff meetings, in-service training, public relations, or travel.

Identification

Temporary Licensee Applicant Name*

Prefix First Middle Last

Temporary Licensee Applicant Home Address*

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

Temporary Licensee Applicant 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

Supervised Experience Setting

Temporary Licensee Applicant Signature*

I understand that this NC SEY Plan submission will only contain: NC Locations, and NC Hours completed at NC Locations serving NC patients. If hours are completed in other state(s) I will follow the instructions previously provided for receiving credit for time completed in other state(s).

Additional Service Locations

Will you be providing services at more than one location?

Yes

No

Address*

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. The Board has jurisdiction over NC locations. If locations that are not in NC are listed the plan cannot be approved.

Street Address Address Line 2 City State ZIP Code

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. The Board has jurisdiction over NC locations. If locations that are not in NC are listed the plan cannot be approved.

× Warning! You must pick a future date!

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. Do not enter a date that is less than 3 days from today’s date!

× Warning! It will take 5-7 business days to process this submission. Don’t plan to start working the same day the plan is submitted!

Supervisor

Name of Supervisor*

Prefix First Middle Last

N.C. License #*

Employer's Name*

Employer's Address*

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

Employer's Phone*

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 an average of four hours per month of direct observation of the applicant’s direct work with patients for full-time employment and an average of 2 hours per month of the applicant’s direct work with patients for part-time employment ,(telesupervision is accepted as direct supervision). Direct supervision is in addition to “other” methods of supervision (e.g. video/audio tape recording review, records review, staff meetings, telephone conferences/correspondence, etc.). It is required that the supervisor provide a total of 36 hours of direct observation of the applicant’s direct work with patients spread out over the 1,260 hours of employment. The temporary licensee must work under their temporary license for a minimum of 9 months and obtain at least 1,260 work hours with at least seventy percent (70%) of their work hours devoted to clinical activities before applying for a permanent license.

Temporary Licensee Applicant Signature*

IF THE SUPERVISOR DOES NOT PROVIDE AN AVERAGE OF 4 HOURS OF DIRECT SUPERVISION PER MONTH FOR FULL-TIME EMPLOYMENT AND AN AVERAGE OF 2 HOURS PER MONTH OF DIRECT SUPERVISION FOR PART-TIME EMPLOYMENT, THE TEMPORARY LICENSEE IS REQUIRED TO NOTIFY THE BOARD IMMEDIATELY.

The average number of hours of supervision should be determined every 3 months. A temporary licensee working full-time (30 or more hours per week) should at no time receive less than 2 hours of direct supervision within a 30-day period. A temproary licensee working part-time (less than 29 hours per week) should at no time receive less than 1 hour of direct supervision within a 30-day period.

Exceptions include times when the temporary licensee is not working. For example, summer breaks in the school system or breaks in year-round schools, delayed the start dates when the license is first issued, maternity or medical leave. Be aware that the breaks in employment do not exempt the temporary licensee from completing all of the SEY requirements within a 24-month period.

An Acceptable 3-month segment looks like:

January – 5 hours of direct observation were provided

Feburary – 2 hours of direct observation were provided

March – 5 hours of direct observation were provided

Non-Acceptable 3-month segment looks like:

January – 3 hours of direct observation were provided

February – 1 hours of direct observation were provided

March – 8 hours of direct observation were provided

How do I send this form to my supervisor?

To send this form to your supervisor click “save and continue later”. Once you are prompted to enter an email address, enter your supervisor’s email address, and click “send link”.

Supervising Licensee Signature*

Note: The Temporary Licensee Applicant must complete 1,260 work hours before applying for their permanent NC license. They will have 18 months to complete the hours. The 18-month period of time will start on the date that their temporary license is issued. One extension may be requested in writing and approved on a case-by-case basis. If the period of supervision has not been completed within 24 months, you will be required to restart your SEY and the hours obtained will not be counted.

At least seventy percent (70%) of your work hours must be 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). Hours not to be included in meeting the 70% requirement are journal groups, administrative activities, staff meetings, in-service training, public relations, or travel.

The average number of hours of supervision should be determined every 3 months. A temporary licensee working full-time (30 or more hours per week) should at no time receive less than 2 hours of direct supervision within a 30-day period. A temproary licensee working part-time (less than 29 hours per week) should at no time receive less than 1 hour of direct supervision within a 30-day period.

Exceptions include times when the temporary licensee is not working. For example, summer breaks in the school system or breaks in year-round schools, delayed the start dates when the license is first issued, maternity or medical leave. Be aware that the breaks in employment do not exempt the temporary licensee from completing all of the SEY requirements within a 24-month period.

An Acceptable 3-month segment looks like:

January – 5 hours of direct observation were provided

Feburary – 2 hours of direct observation were provided

March – 5 hours of direct observation were provided

Non-Acceptable 3-month segment looks like:

January – 3 hours of direct observation were provided

February – 1 hours of direct observation were provided

March – 8 hours of direct observation were provided

Supervising Licensee Signature*

If, at any time, I am unable to continuing the planned supervision of the applicant, I MUST NOTIFY THE BOARD IMMEDIATELY AND SUBMIT THE SUPERVISED EXPERIENCE YEAR REPORT FOR THE PERIOD I SUPERVISED. The applicant must stop practicing until such time that they have obtained a new supervisor, submitted a new SEY plan to the Board, and have been advised by the Board that the new plan has been approved.

Immediately following the last visit of the SEY period, I and the temporary licensee applicant will complete the supervised experience year report provided to me by the Board office. It is suggested that you complete the form in conjunction with the applicant to be certain that all dates are accurate. For online submissions, once the temporary applicant submits the hours, the supervisor will need to login, review, and approve or reject the information entered.

If you choose to complete the form with the applicant online be sure to view the tutorial available on our website located under “Licensees” then click “Temporary Licensee”.

Supervising Licensee Signature*

AS LONG AS THE ABOVE LISTED INDIVIDUAL HOLDS A TEMPORARY LICENSE WITH THIS BOARD YOU ARE REQUIRED TO PROVIDE DIRECT SUPERVISION TO THE ABOVE LISTED INDIVIDUAL EVERY MONTH! MEETING THE BOARD’S MINIMUMS DOES NOT EXEMPT YOU FROM PROVIDING DIRECT SUPERVISION MONTHLY!

Assessment, diagnosis and/or evaluations*

The Board shall interpret Section 90-295(4) to mean the supervision which will be satisfactory to the Board must include an average of four hours per month of direct observation of the applicant’s direct work with patients for full-time employment and an average of 2 hours per month of the applicant’s direct work with patients for part-time employment ,(telesupervision is accepted as direct supervision). Direct supervision is in addition to “other” methods of supervision (e.g. video/audio tape recording review, records review, staff meetings, telephone conferences/correspondence, etc.). It is required that the supervisor provide a total of 36 hours of direct observation of the applicant’s direct work with patients spread out over the 1,260 hours of employment. The temporary licensee must work under their temporary license for a minimum of 9 months and obtain at least 1,260 work hours with at least seventy percent (70%) of their work hours devoted to clinical activities before applying for a permanent license.

Hours of employment per week for the applicant to be spent in assessment, diagnosis and/or evaluations

Planned hours per month of direct supervision in the area of assessment, diagnosis and/or evaluations

Screening*

Hours of employment per week to be spent by the applicant in the area of screenings

Planned hours per month of direct supervision in the area of screenings

Habilitation/rehabilitation/therapy/counseling*

Hours of employment per week to be spent by the applicant in the areas of habilitation/rehabilitation/therapy/counseling

Planned hours per month of direct supervision in the areas of habilitation/rehabilitation/therapy/counseling

Staff meetings*

Hours of employment per week that the applicant will spend in staff meetings.

Record keeping*

Hours of employment per week that the applicant will spend in the area of record keeping.

Other

Please specify in the field below.

Hours of employment per week that the applicant will spend in other areas

Please specify other areas

TOTAL*

Hours of employment per week for applicant

Planned hours per month of direct on-site supervision/area (Average should total at least 4 hours for full time employment and 2 hours for part-time employment)

Number of hours of "other" types of planned supervision activities per month:

To be completed by the Applicant

If your supervisor is not present with you to sign this form, proceed to the bottom of this page, enter your supervisor’s email address, and select “Save and Continue later”. The form can then be completed and submitted by your supervisor.

Signature of Temporary Licensee 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 am seeking licensure. If it is determined at a later date that this statement is not true, I understand that this will slow down the licensure process. I also understand that my SEY Plan will be denied.

Date

To be completed by the Supervisor

If your supervisor is not present to sign, proceed to the bottom of this page and enter your supervisor’s email address. Then select “Save and Continue later”. The form can then be completed and submitted by your supervisor.

Signature of Supervisor*

I have met with and discussed this plan with the applicant and I 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. I understand that by signing off on this SEY Plan I am certifying that I hold a valid N.C. license. I understand that if I do not hold a valid N.C. license I will be in violation of Section § 90-294 (B).

Signature of Supervisor*

If an SEY Plan is submitted with out-of-state address(es) I will make sure that I am maintaining compliance with that state(s) laws, rules, and regulations regarding the delivery of speech-language pathology/audiology services in that/those state(s) as well.

How do I send this form to my supervisee?

To send this form to your supervisee click “save and continue later”. Once you are prompted to enter an email address, enter your supervisee’s email address, and click “send link”.

Notice

Any change in the above plan or a change of supervisor must be reported to the Board PRIOR to implementing the change.

Email Completed Form

If both signatures are present on the form, then you do not need to do anything further with the electronic form submission. If both signatures are not present on the form submission proceed to the bottom of this page, enter your supervisor’s email address, and select “Save and Continue later”. The form can then be completed and submitted by your supervisor.

Email (for PDF delivery)*

Please enter an email address for yourself, your potential supervisor, or an employer receive a copy of this completed form.

OTC Hearing Aids and "Prescription" Hearing Aids Resource Page view page

Revised: SEY Plan

NOTICE TO APPLICANTS FOR TEMPORARY LICENSE

AS LONG AS YOU HOLD A TEMPORARY LICENSE WITH THIS BOARD YOU ARE TO RECEIVE DIRECT SUPERVISION FROM YOUR SUPERVISOR EVERY MONTH! MEETING THE BOARD’S MINIMUMS DOES NOT EXEMPT YOU FROM MONTHLY SUPERVISION!

Identification

Supervised Experience Setting

Supervisor

Clinical and Supervisory Responsibilities

How do I send this form to my supervisor?

AS LONG AS THE ABOVE LISTED INDIVIDUAL HOLDS A TEMPORARY LICENSE WITH THIS BOARD YOU ARE REQUIRED TO PROVIDE DIRECT SUPERVISION TO THE ABOVE LISTED INDIVIDUAL EVERY MONTH! MEETING THE BOARD’S MINIMUMS DOES NOT EXEMPT YOU FROM PROVIDING DIRECT SUPERVISION MONTHLY!

To be completed by the Applicant

To be completed by the Supervisor

How do I send this form to my supervisee?

Notice

Email Completed Form