Fillable Certification of Clinical Competence (California)

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Certification of Clinical Competence (California)

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Application Checklist for Speech-Language Pathologists
Certification of Clinical Competence
(U.S. Graduates)
If you need assistance, please email the Board at
speechandhearing@dca.ca.gov
1. Application
• P
lease remember to submit a 2x2 passport quality photograph
.
2.
F
ee
s
• P
lease submit a check or money order to the Board in the amount of $60.00, mad
e
payable to SLPAHADB.
3.
V
erification of Certification Letter from ASH
A
• O
riginal letter must be mailed from ASHA directly to the Board
.
4.
Fingerprints
• C
alifornia applicants are required to use Live Scan for fingerprinting; please subm
it
a
copy of the completed form to the Board. Fees are paid directly to the Live Sca
n
op
erato
r.
• Out-of-State applicants are required to submit two fingerprint cards (FD-258) and a
c
heck or money order to the Board for $49.00 (DOJ and FBI processing fee). Y
ou
ma
y request fingerprint cards be mailed to you via email a
t
s
peechandhearing@dca.ca.go
v
o O
ne (1) check or money order in the amount of $109 ($60 licensing fee an
d
$
49 fingerprint processing fees) may be submitted. Please make check o
r
m
oney order payable to SLPAHADB
.
NO
TE: Except for Audiology students, experience that was completed after June 30,
2003, without holding a RPE temporary license will not be approved. Please refer to
the Business and Professions Code section 2532.7(b).
If your certification was issued based on the Mutual Recognition Agreement, you do
not qualify for this option. You must apply as a foreign educated applicant.
BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY & HEARING AID DISPENSERS BOARD
1601 Response Road, Suite 260, Sacramento, CA 95815
P (916) 287-7915 | www.speechandhearing.c
a.gov
APPLICATION FOR LICENSURE
CERTIFICATE OF CLINICAL COMPETENCE
$60.00
IMPORTANT: You must hold a current Certificate of Clinical Competence (CCC) issued by the American
Speech-Language-Hearing Association (ASHA) in order to complete this application. If your certification
was issued under the guidelines of the Mutual Recognition Agreement, you must complete the
License Application Package for Foreign Educated.
INSTRUCTIONS: Do not print this application double-sided. Any corrections to this form must be crossed
out and initialed. Make check payable to: SLPAHADB
PLEASE TYPE OR PRINT NEATLY
1. FULL NAME: LAST FIRST MIDDLE
2. OTHER NAMES YOU HAVE USED (INCLUDING MAIDEN):
3. STREET ADDRESS CITY STATE ZIP
4. RESIDENCE TELEPHONE: BUSINESS TELEPHONE:
5. SOCIAL SECURITY NUMBER (SSN) OR INDIVIDUAL TAX IDENTIFICATION
NUMBER (ITIN):
6. DATE OF BIRTH: (MM/DD/YYYY)
7. EMAIL ADDRESS:
8. ARE YOU, A SPOUSE, OR DOMESTIC PARTNER OF ACTIVE DUTY MILITARY PERSONNEL? YES NO
If yes, you may qualify for expedited application processing. An applicant for expedited application processing must meet the
fol
lowing requirements: 1) provide evidence that the applicant is married to, or in a domestic partnership or other legal uni
on
wi
th, an active duty member of the Armed Forces of the United States who is assigned to a duty station in California unde
r
offi
cial active duty orders and; 2) hold a current license in another state, district, or territory of the United States in speech-
language pathology or audiology.
9. ARE YOU AN HONORABLY DISCHARGED VETERAN OF THE ARMED FORCES? YES
NO
If yes, you may qualify for expedited application processing. An applicant for expedited application processing must meet the
following requirement: 1) supply satisfactory evidence to the board that the applicant has served as an active duty member
of the Armed Forces of the United States and was honorably discharged.
10. BUSINESS AND PROFESSIONS CODE SECTION 135.4 PROVIDES THAT THE BOARD MUST EXPEDITE, AND MAY
ASSIST, THE INITIAL LICENSURE PROCESS FOR CERTAIN APPLICANTS DESCRIBED BELOW.
Do any
of the following statements apply to you? YES
NO
•
You were admitted to the United States as a refugee pursuant to section 1157 of title 8 of the United States
Code;
• You were granted asylum by the Secretary of Homeland Security or the United States Attorney General pursuant to
section 1158 of title 8 of the United States code; or,
•
You have a special immigrant visa and were granted a status pursuant to section 1244 of Public Law 110-181, Publi
c
Law 109-
163, or section 602(b) of title VI of division F of Public Law 111-8, relating to Iraqi and Afgha
n
tr
anslators/interpreters or those who worked for or on behalf of the United States governm
ent.
If y
ou selected yes, you must attach evidence of your status as a refugee, asylee, or special immigrant visa holder. Failure to
do so may result in application review delays.
ATTACH 2” X 2”
PASSPORT QUALITY
PHOTOGRAPH HERE.
MUST BE AN ACTUAL PHOTOGRAPH,
NOT A PAPER COPY.
PHOTOGRAPHS MUST BE TAKEN
WITHIN 60 DAYS OF THE FILING DATE
OF THIS APPLICATION
PRINT YOUR FULL NAME ON THE BACK
OF THE PHOTOGRAPH
[APP 100 REV 11/20] Page 1 of 3
11. GRADUATE AND UNDERGRADUATE PROGRAMS
INSTITUTION NAME
MAJOR FIELD
OF STUDY
DEGREE
RECEIVED
DATE DEGREE
RECEIVED
12. Education: Master’s Degree
Master’s Degree Equivalency
13. EMPLOYER:
EMPLOYER’S ADDRESS:
YES
NO
14. Have you taken the Educational Testing Service (ETS)/National Teacher Examination
(NTE) (The Praxis Series) in Speech-Language Pathology within the last five (5) years?
15. In what state was your supervised professional experience or Clinical Fellowship Year?
State:______ Year________
If it was completed in California after June 30, 2003, please complete and submit the Required Professional
_________________________________________
Verification form. Audiologists are exempt under this provision.
A YES answer to any of the questions below (16 through 19), requires you to
complete and submit the Discipline Reporting Form.
YES
NO
1
6. Have you ever been the subject of a disciplinary action or have any pending disciplinary
ac
tion taken or charges filed against any speech-language pathology, audiology
,
hear
ing aid dispensing, or other healing arts license? Include any disciplinary acti
on
t
aken by any other state or federal government entity? This includes but is not limited t
o
s
uspension, revocation, probation, confidential discipline, consent order, letter o
f
reprimand or warning, or any other restriction of actions taken against a license.
17. Have you had any pending investigations by any state or federal agencies against you?
1
8. Have you been denied a license to practice speech-language pathology, audiology,
hearing aid dispensing, or other healing arts, in any state or country?
1
9. Have you voluntarily surrendered a license to practice speech-language pathology,
audiology, hearing aid dispensing, or other healing arts in another state or country?
You must report to the Board the result of any actions which have been filed or are pending against
any speech-language pathology, audiology, or hearing aid dispensers license you hold at the time of
filing this application. Failure to report this information may result in the denial of your application or
subject your license to discipline pursuant to Section 480(c) of the Business and Professions Code.
[APP 100 REV 11/20] Page 2 of 3
I hereby certify under penalty of perjury under the laws of the State of California that all
statements made herein are true in every respect and that misstatements or omissions of
material facts may be cause for denial of this application, or for suspension or revocation of a
license.
Applicant’s Signature
Date
Notice: Effective July 1, 2012, the State Board of Equalization and the Franchise Tax Board may share taxpayer information with
the Board. You are obligated to pay your state tax obligation and your license may be suspended if your tax obligation is not
paid.
[APP 100 REV 11/20] Page 3 of 3
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016
PAGE 1 of 4
(Rev. 04/2020)
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
A0437 License
ORI (Code assigned by DOJ)
Authorized Applicant Type
Speech Pathologist
Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
Speech-Language Pathology & Audiology & Hearing Aid Dispensers Board 06187
Agency Authorized to Receive Criminal Record Information
Mail Code (five-digit code assigned by DOJ)
1601 Response Road, Suite 260 N/A
Street Address or P.O. Box Contact Name (mandatory for all school submissions)
Sacramento CA 95815
City State ZIP Code
Contact Telephone Number
Applicant Information:
Last Name
Other Name: (AKA or Alias)
Last Name
Sex
Male Female
Date of Birth
Height Weight Eye Color Hair Color
Place of Birth (State or Country) Social Security Number
Home
Address
Street Address or P.O. Box
First Name Middle Initial Suffix
First Name
Suffix
Driver's License Number
Billing
Number
(Agency Billing Number)
Misc.
Applicant Must Pay At Site
Number
(Other Identification Number)
City
State ZIP Code
I have received and read the included Privacy Notice, Privacy Act Statement, and Applicant's Privacy Rights.
Applicant Signature
Date
DOJ
FBI
Your Number: 7700 SLP/AU
Level of Service:
OCA Number (Agency Identifying Number)
(If the Level of Service indicates FBI, the fingerprints will be used to check the
criminal history record information of the FBI.)
If re-submission, list original ATI number:
(Must provide proof of rejection)
Original ATI Number
Employer (Additional response for agencies specified by statute):
Not Applicable
Employer Name
Street Address or P.O. Box Telephone Number (optional)
City State
ZIP Code
Mail Code (five digit code assigned by DOJ)
Live Scan Transaction Completed By:
Date
ATI Number
Name of Operator
Transmitting Agency
LSID
Amount Collected/Billed
STATE OF CALIFORNIA
BCIA 8016
(Rev. 04/2020)
DEPARTMENT OF JUSTICE
PAGE 2 of 4
REQUEST FOR LIVE SCAN SERVICE
Privacy Notice
As Required by Civil Code § 1798.17
Collection and Use of Personal Information. The California Justice Information Services (CJIS)
Division in the Department of Justice (DOJ) collects the information requested on this form as authorized
by Business and Professions Code sections 4600-4621, 7574-7574.16, 26050-26059, 11340-11346, and
22440-22449; Penal Code sections 11100-11112, and 11077.1; Health and Safety Code sections 1522,
1416.20-1416.50, 1569.10-1569.24, 1596.80-1596.879, 1725-1742, and 18050-18055; Family Code
sections 8700-87200, 8800-8823, and 8900-8925; Financial Code sections 1300-1301, 22100-22112,
17200-17215, and 28122-28124; Education Code sections 44330-44355; Welfare and Institutions Code
sections 9710-9719.5, 14043-14045, 4684-4689.8, and 16500-16523.1; and other various state statutes
and regulations. The CJIS Division uses this information to process requests of authorized entities that
want to obtain information as to the existence and content of a record of state or federal convictions to
help determine suitability for employment, or volunteer work with children, elderly, or disabled; or for
adoption or purposes of a license, certification, or permit. In addition, any personal information collected
by state agencies is subject to the limitations in the Information Practices Act and state policy. The DOJ's
general privacy policy is available at http://oag.ca.gov/privacy-policy.
Providing Personal Information. All the personal information requested in the form must be provided.
Failure to provide all the necessary information will result in delays and/or the rejection of your request.
Access to Your Information. You may review the records maintained by the CJIS Division in the DOJ
that contain your personal information, as permitted by the Information Practices Act. See below for
contact information.
Possible Disclosure of Personal Information. In order to process applications pertaining to Live Scan
service to help determine the suitability of a person applying for a license, employment, or a volunteer
position working with children, the elderly, or the disabled, we may need to share the information you give
us with authorized applicant agencies.
The information you provide may also be disclosed in the following circumstances:
•With other persons or agencies where necessary to perform their legal duties, and their use
of
y
our information is compatible and complies with state law, such as for investigations or fo
r
l
icensing, certification, or regulatory purposes
.
•
T
o another government agency as required by state or federal law
.
Contact Information. For questions about this notice or access to your records, you may contact the
Associate Governmental Program Analyst at the DOJ's Keeper of Records at (916) 210-3310, by email at
keeperofrecords@doj.ca.gov
, or by mail at:
Department of Justice
Bureau of Criminal Information & Analysis
Keeper of Records
P.O. Box 903417
Sacramento, CA 94203-4170
STATE OF CALIFORNIA
BCIA 8016
(Rev. 04/2020)
DEPARTMENT OF JUSTICE
PAGE 3 of 4
REQUEST FOR LIVE SCAN SERVICE
Privacy Act Statement
Authority. The FBI's acquisition, preservation, and exchange of fingerprints and associated
information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application,
supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544,
Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated
information is voluntary; however, failure to do so may affect completion or approval of your
application.
Principal Purpose. Certain determinations, such as employment, licensing, and security clearances,
may be predicated on fingerprint-based background checks. Your fingerprints and associated
information/biometrics may be provided to the employing, investigating, or otherwise responsible
agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's
Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and
latent fingerprint repositories) or other available records of the employing, investigating, or otherwise
responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI
after the completion of this application and, while retained, your fingerprints may continue to be
compared against other fingerprints submitted to or retained by NGI.
Routine Uses. During the processing of this application and for as long thereafter as your fingerprints
and associated information/biometrics are retained in NGI, your information may be disclosed
pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act
of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register,
including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses
include, but are not limited to, disclosures to: employing, governmental, or authorized non-
governmental agencies responsible for employment, contracting, licensing, security clearances, and
other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice
agencies; and agencies responsible for national security or public safety.
STATE OF CALIFORNIA
BCIA 8016
(Rev. 04/2020)
DEPARTMENT OF JUSTICE
PAGE 4 of 4
REQUEST FOR LIVE SCAN SERVICE
Noncriminal Justice Applicant's Privacy Rights
As an applicant who is the subject of a national fingerprint-based criminal history record check for
a noncriminal justice purpose (such as an application for employment or a license, an immigration
or naturalization matter, security clearance, or adoption), you have certain rights which are
discussed below.
• You must be provided written notification1 that your fingerprints will be used to check the
c
riminal history records of the FBI
.
• You must be provided, and acknowledge receipt of, an adequate Privacy Act Statement
w
hen you submit your fingerprints and associated personal information. This Privacy
Act
S
tatement should explain the authority for collecting your information and how y
our
i
nformation will be used, retained, and shared.
2
•If you have a criminal history record, the officials making a determination of your
s
uitability for the employment, license, or other benefit must provide you the opportunit
y
to complete or challenge the accuracy of the information in the record.
•
The officials must advise you that the procedures for obtaining a change, correction,or
updat
e of your criminal history record are set forth at Title 28, Code of Feder
al
Regulations (CFR), Section 16.34.
•If you have a criminal history record, you should be afforded a reasonable amount of time
t
o correct or complete the record (or decline to do so) before the officials deny you t
he
e
mployment, license, or other benefit based on information in the criminal history record
. 3
You have the right to expect that officials receiving the results of the criminal history record check
will use it only for authorized purposes and will not retain or disseminate it in violation of federal
statute, regulation or executive order, or rule, procedure or standard established by the National
Crime Prevention and Privacy Compact Council.
4
If agency policy permits, the officials may provide you with a copy of your FBI criminal history
record for review and possible challenge. If agency policy does not permit it to provide you a copy
of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI.
Information regarding this process may be obtained at https://www.fbi.gov/services/cjis/identity-
history-summary-checks.
If you decide to challenge the accuracy or completeness of your FBI criminal history record, you
should send your challenge to the agency that contributed the questioned information to the FBI.
Alternatively, you may send your challenge directly to the FBI. The FBI will then forward your
challenge to the agency that contributed the questioned information and request the agency to
verify or correct the challenged entry. Upon receipt of an official communication from that agency,
the FBI will make any necessary changes/corrections to your record in accordance with the
information supplied by that agency. (See 28 CFR 16.30 through 16.34.)
You can find additional
information on the FBI website at https://www.fbi.gov/about-us/cjis/background-checks.
1
Written notification includes electronic notification, but excludes oral notification
2 https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement
3
See 28 CFR 50.12(b)
4
See U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c)
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Certification of Clinical Competence (California)

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Completed 29 July 2021

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