Fillable 2021APPLICATIONFORM CouncilforClinicalCertificationinAudiologyandSpeechLanguagePathology(CFCC) 4YearTerm:January1,2021December31,2024 DeadlineforSubmission:May1,2020 Pleasesubmityourapplication,includ

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2021APPLICATIONFORM CouncilforClinicalCertificationinAudiologyandSpeechLanguagePathology(CFCC) 4YearTerm:January1,2021December31,2024 DeadlineforSubmission:May1,2020 Pleasesubmityourapplication,includingacurrentCV,asanemailattachmenttocfcc@asha.org Name Employer JobTitle (American Speech-Language-Hearing Association)

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  • 15 check-boxes
  • 21 other fields

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



DeadlineforSubmission:May1,2020
Pleasesubmityourapplication,includingacurrentCV,asane‐mailattachmenttocfcc@asha.org
Name
Employer  JobTitle 
WorkAddress
HomeAddress
Work# Home#
CellPhone PreferredE‐mail
Positionforwhichyouwishtobeconsidered:
ASHA‐certifiedAudiologist
ASHA‐certifiedSpeech‐LanguagePathologist
PublicMember

Area(s)inwhichyouholdASHACertification:Audiology Speech‐LanguagePathology
N/A
Primaryareaofemployment: Academic Practitioner
Area(s)inwhichyouholdSpecialtyBoardRecognition:
ChildLanguage FluencyDisorders None
SwallowingandSwallowingDisorders IntraoperativeMonitoring
AreyoucurrentlyservingonotherASHAboardsorcommitteeswhereyourservicewouldoverlapwith
serviceontheCFCC?NoYes(specifytheboard/committeebelow)
2021APPLICATIONFORM
CouncilforClinicalCertificationinAudiologyandSpeech‐LanguagePathology(CFCC)
4‐YearTerm:January1,2021–December31,2024
Page 2 of 4
NOTE:Acurrentcurriculumvitae(CV)—nottoexceed10pages—maybesubmittedasyourresponseto
items1through6(pleasereferencethepagesofyourvitaethatrelatetoeachitem).Item7mustbe
completedasdescribed.
1. Describeyourprimaryemploymentactivity.
2. Describeyoursecondaryemploymentactivity(ifapplicable).
3. Identifyyourexperienceandpresentdutiesinvolvingstudentacademicpreparation.
4. ProvideasummaryofyourpreviousactivitiesonASHAcommittees,boards,and/orcouncils.
Includedatesofserviceandspecificcontributions.
5. Provideasummaryofyouractivitiesinstateand/orlocalspeechandhearingassociation
committees,boards,oroffices,includingdatesofserviceandspecificcontributions.
6. Provideasummaryofyournon‐ASHAprofessionalvolunteeringexperiences(e.g.state
licensingboard,alliedhealthorganization,etc.).Pleaseincludedatesofserviceandspecific
contributions.
Page 3 of 4
7. Provideasummaryofyouractivitiesinalliedandrelatedprofessionalorganizationsorother
organizationsconcernedwithcommunicationdisordersandsciences,includingdatesof
serviceandspecificcontributions.
8. Attachastatement(250wordsorless)detailingtheexpertiseyouwouldbringtotheCFCC.
Includeanyexperienceyouhavehadintheprovisionofclinicalservices,instructionor
supervisionofstudentsand/orclinicalfellows,qualitymanagement,andstandards
development/implementationthatwouldbevaluableforserviceontheCFCC.

Page 4 of 4
MysignaturebelowisverificationofmyinterestanddesireinservingontheCFCC,withmyterm
beginningonJanuary1,2021.

Signature Date
CurriculumVitae:
PleaseattachyourcurrentCV,nottoexceed10pages.
Returnthisnominationformandattachmentsviae‐mailtocfcc@asha.org,orbyfaxormail,nolater
thanMay1,2020to:
CarolAnnRaymond,Chair
CFCCNominatingCommittee
c/oToddPhilbrick
ASHA
2200ResearchBlvd.#313
Rockville,MD20850
Fax:301‐296‐8570
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2021APPLICATIONFORM CouncilforClinicalCertificationinAudiologyandSpeechLanguagePathology(CFCC) 4YearTerm:January1,2021December31,2024 DeadlineforSubmission:May1,2020 Pleasesubmityourapplication,includingacurrentCV,asanemailattachmenttocfcc@asha.org Name E

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Completed 27 August 2020

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