Speech-Language Pathology Assistant Registration 2.0

"*" indicates required fields

Step 1 of 9

11%

Cost: $40 (+$3 for PayPal)

This form may only be completed by the slp requesting the below listed slp-assistant be added to their license. 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. If this form is not signed properly, it will be denied.

Has the assistant been registered with the NC Board of Examiners for Speech-Language Pathologists and Audiologists before?*

If the assistant has not been registered with the NC Board they will need to fill out the assistant application, and you should not continue filling out this form.

Yes

No, this is for a full registration

SLP-Assistant Registration Number*

If you have a temporary registration with the Board be sure to include TEMP in front of your eight digit number. If you are unsure of your registration number please use the Board's lookup function, or contact the Board office at 336-272-1828. If this is the applicants initial registration please put 4 zeros in this field.

Supervisor Information

Name*

Prefix First Middle Last

NC License Number*

How many SLP-Assistants do you currently supervise?*

This should include all SLP-Assistant(s) that you supervise, including under other licenses/registrations you may hold in other jurisdictions. This also includes if you are the secondary supervisor for any SLP Assistant(s).

None

One

Two or more

Primary Supervisor Email*

This email address will be used to send the primary supervisor instructions and a link to the required Performance-Based Competency Assessment & Orientation Checklist.

Enter Email Confirm Email

Do you have a secondary supervisor?*

Yes

Secondary Supervisor's Name*

Prefix First Middle Last

Secondary Supervisor's NC License Number*

How many SLP-Assistants does this licensee currently supervise?*

None

One

Two or more

Assistant Information

Name*

Prefix First Middle Last

Assistant Mailing Address*

Street Address Address Line 2 City State ZIP Code

Primary/Mobile Phone*

Work Phone

Assistant Email*

Enter Email Confirm Email

Academic Information

List

Training Program

Major

Degree

Date

SLP-Assistant Exam Date

Please select the date the exam was passed by the applicant, if they have taken their exam.

Month

Day

Year

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 and state it is for homes. Businesses, schools, Head Start Programs, and daycares require complete names and addresses.

Street Address Address Line 2 City State ZIP Code

Additional Service Locations*

Are there multiple locations where services will be provided?

Yes

Additional Locations*

Please list any additional locations where services will be provided. Complete names and addresses are required for businesses, schools, Head Start Programs, and daycares.

To add rows use "+".

Attestation 1*

I have read and understand that, as the primary supervising licensee I am responsible for all patient services provided by the slp-assistant registered on my license. I understand that I am not able to delegate this responsibility to anyone else (ex. another licensee within the same company/place of employment, secondary supervising licensee, office manager, etc.). Authority 21 NCAC 64 .1003 (e).

I understand

Attestation 2*

I have read and understand that, as the primary supervising licensee even when an evaluation has previously been completed I should personally evaluate/re-evaluate (the evaluation may be formal or informal) each patient on my caseload before assigning any treatment tasks to the slp-assistant registered on my license. For additional licensee requirements not listed above please read 21 NCAC 64 .1003. Authority 21 NCAC 64 .1003 (e)(1).

I understand

Attestation 3*

I have read and understand that, as the supervising licensee I am responsible for being aware of the authorized tasks of speech-language pathology assistants as outlined by 21 NCAC 64 .1004. I understand that, assigning tasks that fall outside of 21 NCAC 64 .1004 can result in possible violation of the statute and rules that govern speech-language pathology licensure in North Carolina. Authority G.S. 90-301A (8).

I understand

Attestation 4*

I have read and understand that, as the primary supervising licensee I am responsible for discussing job expectations and ensuring that there is mutual understanding of job scope and specific responsibilities. This includes and is not limited to, providing regular, formal employment evaluations on a scheduled basis to assess performance, strengths and weaknesses, and establish development goals for continuous performance improvement. For additional supervision and continuing competence requirements not listed above please read 21 NCAC 64 .1005. Authority 21 NCAC 64 .1005.

I understand

Quiz

Knowledge Demonstration for Licensed Speech Language Pathologists to Register a SLP-Assistant. This quiz must be completed by the primary supervisor.

Who must sign every patient encounter (screening or treatment) when services are provided by a SLP-Assistant?*

SLP-Assistant

Secondary Supervisor

Primary Supervisor

Primary Supervisor and SLP-Assistant

The written treatment protocol must include all EXCEPT:*

Specification of the contingent response to the patient's behavior.

Specification of the target behavior

Specification of how the target behavior is to be elicited

Specifications of how data is to be collected

Who is responsible for keeping the Board of Examiners apprised of changes in registration information?*

Primary Supervising Licensee

SLP-Assistant

Both the Primary Supervising Licensee and the Secondary Supervising Licensee

SLP-Assistant

Which of the following is NOT required of a licensee when services are being rendered to the public by a SLP-Assistant?*

The licensee must be accessible to the Assistant

The supervising licensee must be in the same building as the SLP-Assistant

The Patient or family must be informed in writing

The SLP-Assistant must wear a badge including the job title: "Speech-Language Pathology Assistant"

Which is NOT a required element of a session protocol?*

The protocol must be signed by the parent or guardian.

The protocol must be signed by the SLP-Assistant and the supervising licensee.

The protocol must be in writing.

The protocol must specify the eliciting conditions, the target behavior, and the contingent response.

Whose caseload does the SLP-Assistant serve?*

Secondary Supervisor

Primary Supervisor

Any SLP who is employed at the same facility

Both the caseload of the Primary Supervisor and Secondary Supervisor

Who is completely responsible for the services provided by the registered SLP-Assistant?*

Employer

Secondary Supervisor

Primary Supervisor

Board of Examinations

What is included in a written session plan (treatment protocol)?*

the eliciting behavior(s)

All of the above

the eliciting condition

the consequences of target behaviors

What is the correct designator to be used by the SLP-Assistant on all documents?*

SLP-A

SLP-Assistant

Primary Assistant

Assistant

For how many speech-language pathology assistants may a licensed speech-language pathologist who works full-time serve as the Primary Supervisor?*

Assistant Protocol Target Behavior & Feeding and Swallowing Protocol Forms

Attach the completed SAMPLE slp-assistant protocol target behavior form this has to be signed and completed as it would be for a real patient/client*

Download the SLP-Assistant Protocol Target Behavior form, you must complete a sample of this form as your would for a real patient/client your SLP Assistant would be providing services for.

This is to show the Board you understand how to complete the form properly. Please attach the sample below.

Once the SLP Assistant is approved under your license this specific form is required to be completed by the Primary supervising SLP for EACH patient/client based on that clients specific needs/ goals that the SLP Assistant will be using to meet the goals with. Each patient/client's target behavior form will need to remain in their file until a new one is created based on the clients current status and goals .

The Primary SLP will need to evaluate the patient/client and fill out a target behavior form for that patient/client before the SLP Assistant begins providing services and using the target behavior form.

These forms are subject to Board audit at any time.

IF THE SAMPLE ATTACHED TO THIS REQUEST IS INCORRECT OR INCOMPLETE THE REGISTRATION WILL NOT BE ABLE TO BE APPROVED, AND YOU WILL BE REQUIRED TO RESUBMIT.

Max. file size: 50 MB.

Will this slp-assistant be providing feeding/swallowing services?*

Yes, I have attached a sample feeding/swallowing protocol form below.

Attach the completed applicable feeding/swallowing protocol form. This has to be signed.*

Download the SLP-Assistant Feeding/Swallowing Protocol form.This form is for SLP-Assistants who will be providing Feeding and/or Swallowing services within the Board's scope of practice for SLP Assistants.

THIS FORM IS NOT THE SAME AS THE TARGET BEHAVIOR FORM USED ABOVE.

Max. file size: 50 MB.

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 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.

Requirements for completing the treatment protocol form*

I have read and understand the requirements for completing the treatment protocol form.

I have

Requirements for registering an SLP-Assistant*

I have read and understand the Requirements for Registering a SLP-Assistant

I have

Signature of Supervisor*

Date*

Month

Day

Year

Email (for PDF delivery)*

Please enter the primary supervisor's email address listed above to receive a copy of this completed form.

Enter Email Confirm Email

Payment Information

Notice

Any change in the above plan OR supervisor must be reported to the Board PRIOR to implementing the change or continuing the practice.

Upon Submission

Once the Board receives the completed paperwork and fee please allow up to 10 days for processing. To avoid processing delays, updates will not be provided in the duration of the 10 days. Once the request is approved you will receive and email confirming the change. Also, your portal and the website will reflect the approved change.

SLP-Assistant Registration

Payment Options

PayPal (A $3 fee will be added for online payments)

Mail payment with printed form

Mail payment with printed form*

I understand that if I choose to mail in payment with printed form the Board office will not receive my form submission. I understand that the most common reason for delay is error in completing the form correctly, providing the required information, and not following the instructions. Error can be avoided if you proceed through this form submission carefully, thoroughly, and accurately. If you have any questions or need assistance, call the Board of Examiners at 336-272-1828.

I understand

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

Total

SLP-Assistant Registration 2.0

"*" indicates required fields

Step 1 of 9

11%

Cost: $40 (+$3 for PayPal)

This form may only be completed by the slp requesting the below listed slp-assistant be added to their license. 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. If this form is not signed properly, it will be denied.

Has the assistant been registered with the NC Board of Examiners for Speech-Language Pathologists and Audiologists before?*

If the assistant has not been registered with the NC Board they will need to fill out the assistant application, and you should not continue filling out this form.

Yes

No, this is for a full registration

SLP-Assistant Registration Number*

If you have a temporary registration with the Board be sure to include TEMP in front of your eight digit number. If you are unsure of your registration number please use the Board’s lookup function, or contact the Board office at 336-272-1828. If this is the applicants initial registration please put 4 zeros in this field.

Supervisor Information

Name*

Prefix First Middle Last

NC License Number*

How many SLP-Assistants do you currently supervise?*

None

One

Two or more

Primary Supervisor Email*

This email address will be used to send the primary supervisor instructions and a link to the required Performance-Based Competency Assessment & Orientation Checklist.

Enter Email Confirm Email

Do you have a secondary supervisor?*

Yes

Secondary Supervisor's Name*

Prefix First Middle Last

Secondary Supervisor's NC License Number*

How many SLP-Assistants does this licensee currently supervise?*

None

One

Two or more

Assistant Information

Name*

Prefix First Middle Last

Assistant Mailing Address*

Street Address Address Line 2 City State ZIP Code

Primary/Mobile Phone*

Work Phone

Assistant Email*

Enter Email Confirm Email

Academic Information

List

Training Program

Major

Degree

Date

SLP-Assistant Exam Date

Please select the date the exam was passed by the applicant, if they have taken their exam.

Month

Day

Year

Employer Information

Employer Name*

Employer Address

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

Service Locations*

Street Address Address Line 2 City State ZIP Code

Additional Service Locations*

Are there multiple locations where services will be provided?

Yes

Additional Locations*

Please list any additional locations where services will be provided. Complete names and addresses are required for businesses, schools, Head Start Programs, and daycares.

To add rows use “+”.

Attestation 1*

I understand

Attestation 2*

I understand

Attestation 3*

I understand

Attestation 4*

I understand

Quiz

Knowledge Demonstration for Licensed Speech Language Pathologists to Register a SLP-Assistant. This quiz must be completed by the primary supervisor.

Who must sign every patient encounter (screening or treatment) when services are provided by a SLP-Assistant?*

SLP-Assistant

Secondary Supervisor

Primary Supervisor

Primary Supervisor and SLP-Assistant

The written treatment protocol must include all EXCEPT:*

Specifications of how data is to be collected

Specification of the target behavior

Specification of how the target behavior is to be elicited

Specification of the contingent response to the patient’s behavior.

Who is responsible for keeping the Board of Examiners apprised of changes in registration information?*

Both the Primary Supervising Licensee and the Secondary Supervising Licensee

SLP-Assistant

Primary Supervising Licensee

Which of the following is NOT required of a licensee when services are being rendered to the public by a SLP-Assistant?*

The licensee must be accessible to the Assistant

The Patient or family must be informed in writing

The SLP-Assistant must wear a badge including the job title: “Speech-Language Pathology Assistant”

The supervising licensee must be in the same building as the SLP-Assistant

Which is NOT a required element of a session protocol?*

The protocol must be signed by the parent or guardian.

The protocol must specify the eliciting conditions, the target behavior, and the contingent response.

The protocol must be in writing.

The protocol must be signed by the SLP-Assistant and the supervising licensee.

Whose caseload does the SLP-Assistant serve?*

Any SLP who is employed at the same facility

Primary Supervisor

Both the caseload of the Primary Supervisor and Secondary Supervisor

Secondary Supervisor

Who is completely responsible for the services provided by the registered SLP-Assistant?*

Secondary Supervisor

Employer

Primary Supervisor

Board of Examinations

What is included in a written session plan (treatment protocol)?*

All of the above

the eliciting condition

the eliciting behavior(s)

the consequences of target behaviors

What is the correct designator to be used by the SLP-Assistant on all documents?*

Assistant

SLP-Assistant

SLP-A

Primary Assistant

For how many speech-language pathology assistants may a licensed speech-language pathologist who works full-time serve as the Primary Supervisor?*

Assistant Protocol Target Behavior & Feeding and Swallowing Protocol Forms

Attach the completed SAMPLE slp-assistant protocol target behavior form this has to be signed and completed as it would be for a real patient/client*

Download the SLP-Assistant Protocol Target Behavior form, you must complete a sample of this form as your would for a real patient/client your SLP Assistant would be providing services for.

This is to show the Board you understand how to complete the form properly. Please attach the sample below.

Once the SLP Assistant is approved under your license this specific form is required to be completed by the Primary supervising SLP for EACH patient/client based on that clients specific needs/ goals that the SLP Assistant will be using to meet the goals with. Each patient/client’s target behavior form will need to remain in their file until a new one is created based on the clients current status and goals .

These forms are subject to Board audit at any time.

IF THE SAMPLE ATTACHED TO THIS REQUEST IS INCORRECT OR INCOMPLETE THE REGISTRATION WILL NOT BE ABLE TO BE APPROVED, AND YOU WILL BE REQUIRED TO RESUBMIT.

Max. file size: 50 MB.

Will this slp-assistant be providing feeding/swallowing services?*

Yes, I have attached a sample feeding/swallowing protocol form below.

Attach the completed applicable feeding/swallowing protocol form. This has to be signed.*

Download the SLP-Assistant Feeding/Swallowing Protocol form.This form is for SLP-Assistants who will be providing Feeding and/or Swallowing services within the Board’s scope of practice for SLP Assistants.

THIS FORM IS NOT THE SAME AS THE TARGET BEHAVIOR FORM USED ABOVE.

Max. file size: 50 MB.

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 Assistant

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.

Requirements for completing the treatment protocol form*

I have read and understand the requirements for completing the treatment protocol form.

I have

Requirements for registering an SLP-Assistant*

I have read and understand the Requirements for Registering a SLP-Assistant

I have

Signature of Supervisor*

Date*

Month

Day

Year

Email (for PDF delivery)*

Please enter the primary supervisor’s email address listed above to receive a copy of this completed form.

Enter Email Confirm Email

Payment Information

Notice

Any change in the above plan OR supervisor must be reported to the Board PRIOR to implementing the change or continuing the practice.

Upon Submission

SLP-Assistant Registration

Payment Options

PayPal (A $3 fee will be added for online payments)

Mail payment with printed form

Mail payment with printed form*

I understand

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

Total

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

Cost: $40 (+$3 for PayPal)

Supervisor Information

Assistant Information

Academic Information

Employer Information

Quiz

Assistant Protocol Target Behavior & Feeding and Swallowing Protocol Forms

Supervisor & Assistant Consent & Signatures

To be completed by the Assistant

To be completed by the Primary Supervisor

Payment Information

Notice

Upon Submission

SLP-Assistant Registration 2.0

Cost: $40 (+$3 for PayPal)

Supervisor Information

Assistant Information

Academic Information

Employer Information

Quiz

Assistant Protocol Target Behavior & Feeding and Swallowing Protocol Forms

Supervisor & Assistant Consent & Signatures

To be completed by the Assistant

To be completed by the Primary Supervisor

Payment Information

Notice

Upon Submission