FORM SA4
Maryland Department of Health
Board of Examiners for Audiologists, Hearing Aid Dispensers,
Speech-Language Pathologists and Music Therapist
4201 Patterson Avenue, Baltimore, Maryland 21215-2299
Phone 410-764-4725 * Fax 410-358-0273 * TTY/ Maryland Relay Service 1-800-735-2258
Alternative Plan for Obtaining Required Clinical Hours
This form must be completed if you have not obtained the required 25 clinical observation hours and 75
clinical assistance hours from your educational institution.
Applicant (Please Type or Print)
Name:
Last First Middle/Maiden
Address:
Street Apt. #
City State Zip Code
Phone: E-mail
Supervising Speech-Language Pathologist
Name:
Last First Middle/Maiden
Professional Address:
Facility or Company’s Name
Street Suite #
City State Zip Code
Telephone #
This Plan must be approved by the Board and a Limited License issued before any clinical observation or
clinical assisting experience is obtained. Experienced gained in violation of the laws and regulations will not be
accepted as having met the licensure requirements.
The Alternative Plan must ensure that the applicant will obtain the required 25 clinical observation hours and
75 clinical assisting hours within 60 days of the applicant’s receipt of a limited License. The plan shall be
designed and signed by the supervising speech-language pathologist. If the Board does not receive proof of
successful completion of the hours by the end of 90 days, the assistant’s Limited License is void and the
assistant will need to reapply.
The 75 hours of clinical assistance shall include 100% direct supervision by the supervising speech-language
pathologist of the speech-language pathologist assistant during any client contact hours. The first month of
clinical hours must start after the Board approves the Form SA4.
