Fillable FORM SA7: Board of Examiners for Audiologists, Hearing (State of Maryland)

Fill Online, Printable, Fillable, Blank FORM SA7: Board of Examiners for Audiologists, Hearing (State of Maryland) Form

Use Fill to complete blank online STATE OF MARYLAND (MD) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

FORM SA7: Board of Examiners for Audiologists, Hearing (State of Maryland)

On average this form takes 18 minutes to complete

The FORM SA7: Board of Examiners for Audiologists, Hearing (State of Maryland) form is 4 pages long and contains:

  • 0 signatures
  • 101 check-boxes
  • 26 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of Maryland

BROWSE STATE OF MARYLAND (MD) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Revised February 2022
FORM SA7
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
Competency Skills Checklist
At the beginning of the Assistant’s Limited Licensure:
The Supervising Speech-Language Pathologist and the Speech-Language Pathology Assistant should review the
Competency Skills Checklist at the beginning of the period of limited licensure and periodically thereafter.
Discussion of the skills required and review of the Assistant’s progress towards acquiring these skills can prove
useful throughout the limited licensure period. Using the Checklist as a learning tool will provide clear goals
for the Assistant and lead to the successful completion of the Checklist at the end of the nine months of
supervised practice.
After 9 months of supervised practice:
The Competency Skills Checklist is to be completed by the supervising Speech-Language Pathologist after the
Speech-Language Pathology Assistant has completed a minimum of nine (9) months of supervised practice
under a limited license. Completion of the Checklist verifies that the Assistant has acquired the skills and
knowledge needed to receive a full license as a Speech-Language Pathology Assistant.
The Speech-Language Pathology Assistant shall submit the completed Competency Skills Checklist to the
Board at least 60 days before the limited license expiration date.
Revised January 2020
FORM SA7
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
Competency Skills Checklist
Speech-Language Pathology Assistant:
Supervising Speech-Language Pathologist:
Directions: The supervising speech-language pathologist marks Yes or No to indicate that the assistant is
competent and meets the criteria. If the supervisor marks “not applicable” (N/A), the supervisor must include
an explanation.
I.
Interpersonal Skills
Standard: The speech-language pathology assistant actively demonstrates cooperation, adaptability, and
effective communication.
1. Criteria: Deals effectively with the attitudes and behaviors of the patients/clients
Yes No
2. Criteria: Communicates and interacts effectively with supervisor
Yes No
II.
Personal Qualities:
Standard: The speech-language pathology assistant demonstrates professional behavior and confidentiality.
1. Criteria: Demonstrates behaviors of a dependable team member which may include:
Yes No
c. Completes assigned tasks within designated treatment session
b. Submits documentation on time
a. Arrives punctually to appointments with prepared assignments
d. Other:
c. Actively participates in interactions with supervisor
b. Requests assistance from supervisor appropriately
a. Accepts and responds appropriately to constructive criticism
f. Other:
e. Refers patient/client/caregivers/other professionals to the supervising speech-language
pathologist when appropriate
d. Demonstrates insight into patient/client and caregivers attitudes and behaviors
c. Addresses/considers patient/client and significant others cultural needs and values
b. Communicates effectively and with sensitivity the needs of the patient/client, family and
caregivers
a. Maintains appropriate patient/client relationships
Rev
ised February 2022
2. Criteria: Demonstrates appropriate conduct in the work environment, which may include:
Yes No
III.
Technical-Assistant Skills
Standard: The speech-language pathology assistant assists the therapist in providing adequate treatment.
1. Criteria: Maintains a facilitating environment for all tasks
Yes No
a. Adjusts environment to facilitate learning (i.e. lights, noise, etc)
b. Organizes treatment space appropriately
c. Other:
2. Criteria: Selects prepares and presents materials effectively
Yes No
3. Criteria: Complies with documentation standards
Yes No
4. Criteria: Provides assistance to the supervising speech-language pathologist
Yes No
IV.
Screenings
Standard: The speech-language pathology assistant will provide appropriate screening procedures.
1. Criteria: Administers screening tools appropriately as directed by the supervisor for communication and/or
swallowing disorders which may include
Yes No
a. Differentiates correct vs. incorrect responses
b. Completes screening protocol form accurately
a. Assists the supervisor as directed during assessments by the speech-language
pathologist
b. Assist with informal documentation
c. Schedules activities appropriately
d. Participates with the supervisor in research projects
e. Participates in in-services training
f. Participates in public relations programs
g. Performs checks and maintenance of equipment
d. Prepares and maintains client records, charts, graphs, objective data as directed by the
supervisor
c. Signs documents and assures co-signature when required
b. Documents client progress and performance to supervisor
a. Documents treatment plans and protocols accurately, completely and concisely for the
supervising speech-language pathologist
c. Recognizes own professional limitations and performs within the boundaries of training
and job responsibilities
b. Maintains professional appearance for work environment
a. Maintains confidentiality of client information at all times
a. Selects and prepares appropriate treatment materials
b. Selects treatment materials based on clients age, needs, culture and motivation
FORM SA7
Revised February 2022
2. Criteria: Manages screening
Yes No
3. Criteria: Communicates results to supervising speech-language pathologist
No
V.
Treatment
Standard: The speech-language pathology assistant provides appropriate treatment
resulting in optimal client improvement.
1. Criteria: Performs treatment tasks as outlined by the supervisor
Yes No
a. Accurately and efficiently follows treatment plans developed by the speech-language
pathologist
b. Incorporates feedback from speech-language pathologist for modifying own behavior
with the client, caregivers and other professional staff
2. Criteria: Manages client behavior and provides appropriate treatment
Yes No
3. Criteria: Demonstrates knowledge of treatment objectives and plan
Yes No
I verify that, ,
Speech-Language Pathology Assistant has completed a minimum of nine (9) months of supervised practice as a
Speech-Language Pathology Assistant under my supervision and has obtained the knowledge and skills needed
to obtain a full license as a Speech-Language Assistant.
Supervising Speech-Language Pathologist Date
a. Demonstrates understanding of client disorder and needs
b. Identifies correct vs. incorrect responses
c. Identifies client behaviors which demonstrate an improvement in function
d. Accurately reports completion of tasks
a. Maintains on-task behavior
b. Provides appropriate feedback to the client as to the accuracy of the response
c. Uses feedback and reinforcement that are consistent, discriminating and meaningful
d. Gives direction and instructions that are age, education and culturally appropriate
e. Implements treatment objectives/goals in specified sequence
f. Applies behavior modification and other reinforcement behavior appropriately as
designated by the speech language pathologist
a. Seeks guidance when appropriate
b. Provides descriptive behavioral observations that contribute to results
c. Organizes screening materials
b. Schedules screenings
a. Reports any difficulties encountered with screening procedures
Yes
FORM SA7
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

FORM SA7: Board of Examiners for Audiologists, Hearing (State of Maryland)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 May 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document