SLP-Assistant Competency Checklist

Supervisor Information
THIS MAY ONLY BE COMPLETED BY THE BOARD APPROVED SUPERVISING SLP, THIS FORM MAY NOT BE COMPLETED BY ANOTHER SLP, THE SLP-ASSISTANT, OR OFFICE STAFF.
Primary Supervisor*
Prefix First Middle Last
NC License Number*
Assistant Information
Name*
Prefix First Middle Last
NC Registration Number*

Save and Continue Later

Summary
Were there any unmet standards?*
- Yes
- No
Action plans for unmet standards
Signature of Speech Language Pathology Assistant*
Registration Number*
Date*
MM slash DD slash YYYY
Signature of Primary Supervising Licensee*
Registration Number*
Date*
MM slash DD slash YYYY
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.

Save and Continue Later

Supervisor Information