SLP-Assistant Supervision Changes

Cost: $20
THIS FORM MAY ONLY BE COMPLETED BY THE BOARD APPROVED SUPERVISING SLP. THIS FORM MAY NOT BE COMPLETED BY ANOTHER SLP, SLP-ASSISTANT, OR OFFICE STAFF.*
BY SIGNING I CERTIFY THAT I, THE POTENTIAL SUPERVISING SLP FOR THIS REGISTRANT IS COMPLETING THIS FORM AS REQUIRED BY ARTICLE 22.
Assistant Information
Name*
Prefix First Middle Last
Registration Number*
Address*
Street Address Address Line 2 City State 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)
MM slash DD slash YYYY
SLP-Assistant’s hours per week under this supervision*

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Primary Supervisor Information
Primary Supervisor*
Prefix 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 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.

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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 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 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. We must have address locations for each location the SLP-Assistant is providing services (DO NOT JUST LIST DAYCARES WITHOUT GIVING THE NAME AND ADDRESS). With the exception being home locations, we just need the general town/ city area the home service is provided.

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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.
Max. file size: 50 MB.
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
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 (for PDF delivery)*
Please enter the Supervising SLP's email address to receive a copy of this completed form.
Payment Information
Payment Options*
- PayPal (A $2 fee will be added for online payments)
- Mail Payment with printed form
SLP-Assistant Supervision Changes Fee
Total
$0.00
Payment Method*

American Express
Discover
MasterCard
Visa
Maestro
Supported Credit Cards: American Express, Discover, MasterCard, Visa, Maestro
Card Number Expiration Date Security Code Cardholder Name
Upon submission of this form, an email will be sent to the address provided above. The email will contain an attached PDF and a link to a PDF of the form you completed. Please print your form and return with payment.

Checks/money orders are made payable to NCBOESLPA, and should be mailed to:
NCBOESLPA
PO Box 16885
Greensboro, NC 27416

The form and check/money order MUST come together. If a check/money order comes in without a form, or vice versa, it will be returned to the sender.

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Audiology & Speech-Language Pathology Interstate Compact Information Page

Step 1 of 5

Cost: $20

Assistant Information

Primary Supervisor Information

Secondary Supervisor Information

Employer Information

Quiz

SLP-Assistant Protocol Target Behavior Form

Performance-Based Competency Assessment & Orientation Checklist for SLP-Assistants

Supervisor & Assistant Consent & Signatures

To be completed by the SLP-Assistant

To be completed by the Primary Supervisor

Payment Information

Assistants