Assistant Supervision Changes

Cost: $20 (+$3 for PayPal)
This form may only be completed by the Board approved supervising licensee. This form may not be completed by another licensee, assistant, or office staff.*
By signing I certify that I, the potential supervising licensee 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*
- Assistant will no longer work under previous supervisor
- This is additional employment. Assistant will continue to work under previous Primary Supervisor as well.
Preferred Start Date (must be a future date)
Month
Day
Year
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 Assistants the Primary Supervisor is the primary supervisor for.*
This # is not including this 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 Assistants the Secondary Supervisor is the secodary supervisor for.
This # is not including this 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 the Assistant 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 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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Signature*
I understand that if I do not pass the quiz my paperwork cannot be processed until the Board office receives a passing score.

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Assistant Protocol Target Behavior Form
Attach the completed applicable Protocol Target Behavior Form THIS HAS TO BE SIGNED*
Download SLP-Assistant Protocol Target Behavior form to be completed and submitted with this application. This form is for SLP-Assistants.
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 an Assistant*
I have read and understand the Requirements for Registering an SLP-Assistant. I have read and understand the Requirements for Registering an Audiology 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. Click here to download Section .1101-.1005 Requirements for the Use of Audiology Assistants in Direct Service Delivery in North Carolina.
To be completed by the Assistant
I have read the applicable Section pertaining to the supervision requirements for the Assistant I will be supervising (Section .1000-.1005 of Article 22 Licensure Act for Speech-Language Pathologists and Audiologists Requirements for the Use of Speech-Language Assistants in Direct Service Delivery in North Carolina, or Section .1101-.1005 Requirements for the Use of Audiology Assistants in Direct Service Delivery in North Carolina), and I agree to abide by all of its requirements. I also certify that all information provided in this application is correct.
Signature of Assistant*
Date
Month
Day
Year
To be completed by the Primary Supervisor
As supervisor of the above listed applicant, I have read the applicable Section pertaining to the supervision requirements for the Assistant I will be supervising (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 or Section .1101-.1005 Requirements for the Use of Audiology Assistants in Direct Service Delivery in North Carolina) 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 Assistant. I understand that I or the above named Secondary Supervisor if one is listed, must be available to the Assistant while they are providing services. I also certify that all information in this application is correct.
Signature of Supervisor*
If your supervisor needs to sign the form, the PDF file that is emailed may be printed, signed, then submitted.
Email (for PDF delivery)*
Please enter the Supervising licensees email address to receive a copy of this completed form.
Payment Information
Payment Options*
- PayPal (A $3 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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Guidance for OTC Hearing Aids View Announcement

Step 1 of 6

Cost: $20 (+$3 for PayPal)

Assistant Information

Primary Supervisor Information

Secondary Supervisor Information

Employer Information

Quiz

Assistant Protocol Target Behavior Form

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

Supervisor & Assistant Consent & Signatures

To be completed by the Assistant

To be completed by the Primary Supervisor

Payment Information

Assistants