Fillable Maryland Department of Health Board of Examiners for (State of Maryland)

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Maryland Department of Health Board of Examiners for (State of Maryland)

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The Maryland Department of Health Board of Examiners for (State of Maryland) form is 2 pages long and contains:

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  • 10 check-boxes
  • 65 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of Maryland

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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
Verification of Supervision for
Speech-Language Pathology Clinical Fellowship Year
***Applicant, please check if any of the following apply regarding the submission of this form:
Change in Employment Site Additional Site
Additional Supervisor Change in Hours
Change of Supervisor
1.
Applicant (Please type or print)
A.
Name:
Last First Middle/Maiden
B.
Address:
Street Apt.
City State Zip Code
Phone: Alternate # Email
C.
Academic Status:
College Degree Date Awarded
D.
Employment Setting:
1.
Facility Name:
2.
Street Address:
City State Zip Code
Phone: Fax:
3.
Beginning date of employment:
Month Day Year
4.
Hours per week spent in Speech-language Pathology?
5.
Is applicant completing a CFY?
Fo
rm AS2
Revised February 2022
Yes No
( )
( )
( )
II.
Supervisor of Limited Licensure year (please print or type)
A.
Name:
Last First Middle/Maiden
B.
Street Address:
City State Zip Code
C.
Place of Employment:
Facility Name
Street
City State Zip Code
Phone: Alternate #
III.
Clinical and Supervisory Responsibility
Applicant
Activity
Hours/Week
Spent by Applicant
Hours/Month Spent by Supervisor
On-Site Observation
(at least 4 hour per month)
Other Monitoring Activities
(optional)
1. Assessment, diagnosis
and/or evaluations
2. Screening
3. Habilitation/
rehabilitation
4. Staff Meetings
5. Supervisory
Conferences
6. In-Service Training
7. Record Keeping
8. Other (Must Specify)
Total
Signature of Applicant _ Date
Signature of Supervisor Date
Supervisor:
Holds ASHA CCC-SLP, ASHA Certificate #
Holds MD License in Speech-Language Pathology, License #
Holds License in Speech-Language Pathology in State of
Form AS2
Revised February 2022
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Maryland Department of Health Board of Examiners for (State of Maryland)

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Completed 9 May 2022

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