Fillable CERTIFICATE OF CLINICAL COMPETENCE RETIRED AFFIDAVIT (American Speech-Language-Hearing Association)

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CERTIFICATE OF CLINICAL COMPETENCE RETIRED AFFIDAVIT (American Speech-Language-Hearing Association)

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Please email a PDF copy of your completed Retired Affidavit to cccmaintenance@asha.org or mail to:
ASHA 2200 Research Blvd. #313 Rockville, MD 20850
1
CERTIFICATE OF CLINICAL COMPETENCE
RETIRED AFFIDAVIT
Print, complete, and submit this form to ASHA by any method listed at the bottom of this page.
ASHA ID: ASHA Certificate Type: □ CCC-A □ CCC-SLP
Name: Previous Name(s) Used:
Address:
Street City State Zip
Daytime Phone: Evening Phone:
E-mail:
Retired certification is available to certificate holders who are in good standing, have retired from
practice, and have held ASHA certification for at least 25 total years OR are 65 years of age or older.
Retired certification status allows you to remain affiliated with ASHA and still append the CCC-A
(Retired) and/or CCC-SLP (Retired) designation to your name. If approved, you will no longer be
required to meet the certification maintenance professional development requirements.
Please note: Retiring your certification alone does not result in a reduction in annual
dues/fees; only certified members who also qualify for Life Membership at the time they retire their
certification are eligible for a reduction in their annual dues/fees. If you retire your certification and are
not yet eligible for Life Membership, you will continue to pay the same rate for your annual dues/fees.
Please verify your eligibility below—you must be able to answer “yes” to one of these statements:
I am 65 years of age or older*.
□ Yes □ No
I have held the Certificate of Clinical Competence for at least 25 total years.
□ Yes □ No
*If your ASHA account does not contain your date of birth, you may be contacted to provide a copy of your driver’s
license, birth certificate, or other document bearing your date of birth. If you are already a Life Member, you will
not be asked to provide any further documentation.
If you wish to discontinue your membership and certification, you must complete and submit the CCC
Resigned Affidavit – please be aware that doing so will cause a break in consecutive years of ASHA
membership and make you ineligible for Life Membership.
Please email a PDF copy of your completed Retired Affidavit to cccmaintenance@asha.org or mail to:
ASHA 2200 Research Blvd. #313 Rockville, MD 20850
2
I wish to retire my Certificate of Clinical Competence (CCC), change my certification status
to CCC-A (Retired) or CCC-SLP (Retired), and continue my affiliation with ASHA. My
signature below provides the assurance that I understand that I am changing my
certification status, and have read and agree to abide by all of the following requirements:
1. The retirement of my CCC-A or CCC-SLP has changed my certification status to CCC-A (Retired) or
CCC-SLP (Retired). This change may impact my current membership status and options for continued
affiliation as a valued ASHA member.
2. I am retired from clinical practice.
Clinical practice
is defined as providing or supervising the provision
of clinical services.
3. I do not and will not mentor or supervise a Clinical Fellow.
4. I do not and will not provide or supervise clinical services.
Clinical servic
es are defined as evaluation
and treatment of persons with speech-language and/or hearing impairments, whether such services
are provided in elementary or secondary schools, in private practice, or in free-standing community
clinics, rehabilitation centers, hospitals, nursing homes, or other facilities.
5. I will continue to abide by the current Code of Ethics of the American Speech-Language-Hearing
Association.
6. My CCC-A (Retired) or CCC-SLP (Retired) status may be made available to the public.
7. The CCC-A (Retired) or CCC-SLP (Retired) status no longer requires that I meet certification
maintenance professional development requirements; however, my CCC-A (Retired) or CCC-SLP
(Retired) status is contingent upon payment of annual membership dues and fees upon receipt of
the annual invoice.
8. I will cease using the designation CCC-A or CCC-SLP and will instead use the designation CCC-A
(Retired) or CCC-SLP (Retired) upon approval of my retirement status.
9. If I decide I want to hold the CCC again, I must go through the certification reinstatement process.
My application will then be subject to reinstatement procedures current at that time, which may
include completing professional development hours and retaking the national Praxis exam.
I affirm that the information provided in this affidavit is accurate.
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CERTIFICATE OF CLINICAL COMPETENCE RETIRED AFFIDAVIT (American Speech-Language-Hearing Association)

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Completed 27 August 2020

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