SLP-Assistant Competency Checklist

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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*

0 of 8 max characters

Assistant Information

Name*

Prefix First Middle Last

NC Registration Number*

0 of 5 max characters

Instructions

The primary supervising speech-language pathologist will complete this competency and orientation document during the first sixty (60) days of employment and forward the signed, original copy to the Board of Examiner’s (the Board) office within 30 days of completion. A new competency assessment and orientation must be completed whenever the licensee who registers the assistant changes.

Qualifications and Employment Overview

The speech-language pathology assistant has completed an approved course of study acceptable to the Board, is currently registered with the Board, and is in good standing as a speech-language pathology assistant.*

Meets standard

Does not meet standard

The speech-language pathology assistant has completed an employment orientation at all sites where speech-language services will be delivered by the assistant.*

Meets standard

Does not meet standard

The speech-language pathology assistant knows and understands the approved rules for SLP-assistants, specifically Attachment 1 (Summary of Authorized Tasks and Supervision Requirements for SLP-Assistants).*

Meets standard

Does not meet standard

The supervising speech-language pathologist has informed the SLP-Assistant of the overall scope of his/her duties and responsibilities in the specific employment context.*

Meets standard

Does not meet standard

Direct Services to Patients/Clients

The speech-language pathology assistant conducts self in a courteous and appropriate manner in all communication and interaction with clients/patients, families, caregivers, and other staff*

Meets standard

Does not meet standard

The speech-language pathology assistant identifies self as a speech-language pathology assistant when greeting client and/or family.*

Meets standard

Does not meet standard

The speech-language pathology assistant wears a name tag at all times which identifies him/her as an assistant.*

Meets standard

Does not meet standard

The speech-language pathology assistant provides instructions and/or explanations of treatment to the patient/client which are clear and complete, and are appropriate for the patient/client’s developmental level, language use, communication disorder, and level of understanding.*

Meets standard

Does not meet standard

The speech-language pathology assistant has been instructed in the proper administration of the screening instruments/tests which will be used in the employment setting(s) and accurately administers these screening instruments, as prescribed by the supervising speech-language pathologist.*

Meets standard

Does not meet standard

The speech-language pathology assistant accurately scores and reports the results of screening tests to the supervising speech-language pathologist.*

Meets standard

Does not meet standard

The speech-language pathology assistant prepares treatment/screening materials before the beginning of each treatment/screening session, as directed by the supervising speech-language pathologist, assuring that such materials are appropriate to the patient/ client’s age, developmental level, culture, and communication disorder.*

Meets standard

Does not meet standard

The speech-language pathology assistant starts and ends treatment sessions on time and follows the written treatment protocol developed and prescribed by the supervising speech-language pathologist.*

Meets standard

Does not meet standard

Health and Safety Standard

The speech-language pathology assistant utilizes universal precautions and adheres to the infection control procedures and guidelines of the employer(s).*

Meets standard

Does not meet standard

The speech-language pathology assistant will use appropriate procedures for the physical management of patients/clients and any necessary injury prevention strategies consistent with the employer’s policies and with state regulation.*

Meets standard

Does not meet standard

Summary

Were there any unmet standards?*

Yes

Action plans for unmet standards

Signature of Speech Language Pathology Assistant*

Registration Number*

Date*

MM slash DD slash YYYY

Signature of Primary Supervising Licensee*

License Number*

0 of 8 max characters

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

Email (for PDF delivery)*

Please enter an email address to receive a copy of this completed form.

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

Supervisor Information

Assistant Information

Instructions

Qualifications and Employment Overview

Direct Services to Patients/Clients

Health and Safety Standard

Summary

Email print version of completed form

Assistants