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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  • 56 check-boxes
  • 381 other fields

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For Office Use Only
Received CK ( ) MO ( ) Number
Revised April, 2020
Maryland Department of Health
Board of Examiners for Audiologists, Hearing Aid Dispensers
and Speech-Language Pathologists
4201 Patterson Avenue, Baltimore, Maryland 21215-2299
Phone 410-764-4725 Fax 410-358-0273
TTY/ Maryland Relay Service 1-800-735-2258
Application for Licensure for Speech-Language Pathology Assistant
Date
Please Read The Application Checklist Before Completing Application Below:
Name
Last First Middle/Maiden
Date of Birth Social Security #
Residence
Street Apt.
City State Zip Code
Phone # Alternate# E-Mail
What is your first language? English Other _____________________________
If answered Other, TOEFL Scores are required. English as a Second Language (ESL) applicants are
required to have a minimum combined Test of English as a Foreign Language (TOEFL) score of 80%
within the previous two years from the date of the application. A copy of you exam scores must be
submitted with your application.
Professional Address
Facility or Company’s Name
Street Suite #
City State Zip Code
Telephone # Fax E-mail
Beginning Date of Employment
Affix
Current
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Received CK ( ) MO ( ) Number
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Have you ever been convicted of a felony or a misdemeanor involving moral turpitude?
No Yes If “Yes” attach full details.
Waiver of Requirements
A.
Do you hold a valid American Speech-Language-Hearing Association Registration as a speech-
language pathology assistant?
No Yes If yes, date originally granted:
Attach copy of ASHA SLP Assistant Registration or letter from ASHA verifying registration as an
SLP Assistant. Also attach Delegation Agreement (Form SA6) completed by each supervising
speech-language pathologist.
B.
Do you hold a valid license, certification or registration as a speech-language pathology assistant
in another state? No _ Yes
If yes, list State(s):
Attach copy of SLP Assistant license, certification or registration from the State. Send affidavit
(Form SA8 – last page of application) verifying license, certification, or registration to the State(s)
and ask that it be returned to the Maryland Board. Also attach Delegation Agreement (Form SA6)
completed by each supervising speech-language pathologist.
Has any disciplinary action ever been taken against your license in any other jurisdiction?
Yes _ If yes, please attach full explanation.
C.
Have you practiced as a SLP Assistant for at least two years prior to submitting this application?
No Yes If yes, attach a letter from your supervising speech-language
pathologist attesting to the dates you have practiced as a SLP Assistant. Also attach Delegation
Agreement (Form SA6) for each supervising Speech-Language Pathologist and completed
Competency Skills Check List, (Form SA7).
Education
An applicant must have graduated within 5 years prior to application:
A.
School attended:
Address:
Dates Attended: From To:
Degree Granted: Date:
Have School send official transcript verifying education completed directly to the Maryland Board.
B.
Please indicate whether you have one of the following degrees:
1. Associate Degree from an approved SLP Assistant Program? _ Yes _ _No
No
_
For Office Use Only
Received CK ( ) MO ( ) Number
Revised April, 2020
2. Associate Degree in an allied health field with 15 hours in required minimum course work?
Yes No
If you have an Associate Degree in an allied health field, complete Form SA2 describing required
minimum coursework as stated on transcript. If the title of the course is not self-explanatory, attach
catalog description or syllabus.
3. Bachelor’s Degree in Speech-Language Pathology or Communication Disorders?
Yes _ No
C.
Did your educational program include the following required clinical hours as a Speech-
Language Pathology Assistant?
25 hours of clinical observation Yes No
75 hours of clinical assistance Yes No
If you did not attend an approved SLP Assistant Program, attach Form SA3 signed by the
Department Chair or Clinic Director documenting the required clinical hours.
If your educational program did not include the required clinical hours, complete Form SA4
documenting the Plan that you and the supervising speech-language pathologist have developed to
complete the clinical hours within the first 60 days of limited licensure.
Pactice Setting Where Limited Licensee Will Practice
Name of Facility
Address:
Phone Number: Beginning Date:
Description of Duties:
Supervising Speech-Language Pathologist (s):
Name Title
Name Title
Name Title
Note: A Delegation Agreement, Form SA6, must be submitted for each supervising Speech-
Language Pathologist.
For Office Use Only
Received CK ( ) MO ( ) Number
Revised April, 2020
Please review the regulations and sign the following affirmation:
I affirm that I have read the Speech-Language Pathology Assistant regulations, including
the sections specifying activities that are within the scope of practice of SLP Assistants
and activities that are not with the scope of practice of SLP Assistants.
Signature of Applicant Date
Applicant Must Have This Affidavit Completed by a Notary Public
State of
City or County of
The undersigned, being duly sworn deposes and says that he/she is the person who executed this
application, that the statements herein contained are true to the best of his/her knowledge, that
he/she has not suppressed any information that might affect this application and that he/she has read
and understands this affidavit.
Signature of Applicant Signature of Notary
Subscribed and sworn to before this day of
In accordance with Executive Order 01.01.1093-18, the Board is required to advise you as follows
regarding the collection of personal information:
Personal information requested by the Board is necessary in determining your eligibility for
licensure. Such personal information is also intended for use as an additional means of verifying the
licensee’s identity or to enable the Board to communicate, in a timely manner, with the licensee
should the need arise. The licensee has a right to inspect his personal record and to amend or correct
the personal data if necessary. Your Social Security Number is needed on the application. It will be
used for identification purposes and may be released to the Department of Public Safety and
Correctional Services to check for any criminal convictions.
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Received CK ( ) MO ( ) Number
Revised April, 2020
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Race/Ethnic Identification
To further its commitment to equal access the Board of Examiners requests applicants to provide,
voluntarily, the following information. This information will be used for statistical purposes only
by authorized personnel.
Male _ Female _ Other _____________________________
Race/Ethnic Identification – Please Check All That Apply
Are you of Hispanic or Latino origin? _ _ Yes _ _ No (A person of Cuban, Mexican, Peurto
Rican, South or Central American, or other Spanish culture or origin, regardless of race.)
Select one or more of the following racial categories:
1. American Indian or Alaska Native (A person having origins in any of the original peoples of
North or South America, including Central America, and who maintains tribal affiliations or
community attachment.)
2. _ Asian (A person having origin in any of the original peoples of the Far East, Southeast Asia,
or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and Vietnam.)
3. Black or African American (A person having origins in any of the black racial groups of
Africa.)
4. Native Hawaiian or other Pacific Islander (A person having origins in the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.)
5. White (A person having origins in any of the original peoples of Europe, the Middle East, or
North Africa.)
SLP-A
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Received CK ( ) MO ( ) Number
Revised April, 2020
Form SA2
Maryland Department of Health
Board of Examiners for Audiologists,
Hearing Aid Dispensers and Speech-Language Pathologists
4201 Patterson Avenue, Baltimore, Maryland 21215-2299
Phone 410-764-4725 Fax 410-358-0273
TTY/ Maryland Relay Service 1-800-735-2258
Associate Degree in Allied Health Field
Verification of Minimum Required Coursework
Applicant (please type or print)
Name:
Last First Middle/Maiden
Address:
Street Apt. #
City State Zip Code
Phone #: Alternate #:
Educational Institution
Name of Institution:
Address:
Street
City State Zip Code
Dates Attended: From To
Associate Degree in granted
(major) (date – mm/dd/yyyy)
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Received CK ( ) MO ( ) Number
Revised April, 2020
Form SA2
The Board’s regulations require that an applicant with an Associate’s Degree in an allied health
field from an accredited institution has completed at least 3 credit hours in each of the areas listed
below. Please indicate the name of the course on the transcript that fulfills each requirement and
attach an official transcript showing the Associate Degree. If the title of the course is not self-
explanatory, attach catalog description or syllabus. A minimum of 3 credit hours is required in each
of the following areas:
Normal Speech-Language Development
Name of Course
Semester Taken
Additional Courses in this area:
Speech Disorders
Name of Course
Semester Taken
Additional Courses in this area:
Anatomy and Physiology of Speech Systems
Name of Course
Semester Taken
Additional Courses in this area:
Language Disorders
Name of Course
Semester Taken
Additional Courses in this area:
Phonology
Name of Course
Semester Taken
Additional Courses in this area:
For Office Use Only
Received CK ( ) MO ( ) Number
Revised April, 2020
Form SA3
Maryland Department of Health
Board of Examiners for Audiologists, Hearing Aid Dispensers
and Speech-Language Pathologists
4201 Patterson Avenue, Baltimore, Maryland 21215-2299
Phone 410-764-4725 * Fax 410-358-0273 * TTY/ Maryland Relay Service 1-800-735-2258
Educational Institution Verification of Completion of Required Clinical Hours
The Board’s regulations require that the speech-language pathology assistant shall demonstrate
completion of at least 25 hours of clinical observation and 75 hours of clinical assistance experience
obtained within an educational institution or in one of the institution’s cooperating programs.
Applicant (Please Type or Print)
Name:
Last First Middle/Maiden
Address:
Street Apt. #
City State Zip Code
Phone: Alternate Phone:
Name of Educational Institution:
Address:
Street
City State Zip Code
Dates Attended (mm/yy): From to
Verification
I verify that completed the following clinical
Applicant
observation hours and clinical assistance hours during the time he/she was a student at
educational institution.
25 Clinical Observation Hours Completed From to
75 Clinical Assistance Hours Completed From to
Signature Title
Print Name Phone
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Received CK ( ) MO ( ) Number
Revised April, 2020
FORM SA4
Maryland Department of Health
Board of Examiners for Audiologists, Hearing Aid Dispensers
and Speech-Language Pathologists
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 Temporary License is void and the assistant will need to
reapply.
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Received CK ( ) MO ( ) Number
Revised April, 2020
FORM SA4
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.
Pursuant to COMAR 10.41.11.08(B) “a licensed full-time (35 hours or more a week) speech-
language pathologist may not supervise more than the equivalent of two full-time (35 hours or more
a week) speech-language pathology assistants.” Pursuant to COMAR 10.41.11.08(C) “a licensed
part-time (35 hours or more a week) speech-language pathologist may not supervise more than the
equivalent of one full-time (35 hours or more a week) speech-language pathology assistant.” The
Board will not issue a full SLP-A license or limited SLP-A license to an applicant until it is satisfied
that the supervisor noted on the Form SA4 is in compliance with the foregoing regulations.
Alternative Plan for Clinical Hours
First Month: Week One from to
Estimated Observation Hours Estimated Assistance Hours
First Month: Week Two from to
Estimated Observation Hours Estimated Assistance Hours
First Month: Week Three from to
Estimated Observation Hours Estimated Assistance Hours
First Month: Week Four from to
Estimated Observation Hours Estimated Assistance Hours
Second Month: Week Five from to
Estimated Observation Hours Estimated Assistance Hours
Second Month: Week Six from to
Estimated Observation Hours Estimated Assistance Hours
Second Month: Week Seven from to
Estimated Observation Hours Estimated Assistance Hours
Second Month: Week Eight from to
Estimated Observation Hours Estimated Assistance Hours
Signature of Applicant Date
Signature of Supervisor Date
Supervisor: (select one of the following)
( ) Holds MD License in Speech-Language Pathology
( ) Holds ASHA CCC-SLP
( ) Holds Licensure in SLP in State of
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Received CK ( ) MO ( ) Number
Revised April, 2020
FORM SA5
Maryland Department of Health
Board of Examiners for Audiologists, Hearing Aid Dispensers
and Speech-Language Pathologists
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 Completion of Required Clinical Hours
The limited licensee must submit the Form SA5 to the Board when the assistant has completed the
required 25 clinical observation hours and 75 clinical assistance hours. The required hours must be
completed within the first 60 days of Limited Licensure. This form must be submitted to the Board
by the end of 90 days of receipt of a Limited License as specified in the letter received with the
limited license. If this form is not submitted by the date specified in the letter enclosed with the
limited licensee the limited license becomes null and void per COMAR 10.41.11.03(B)(2)(e).
Applicant (Please Type or print)
Name:
Last First Middle/Maiden
Address:
Street Apt. #
City State Zip Code
Phone:
Supervising Speech-Language Pathologist
Name:
Last First Middle/Maiden
Professional Address:
Facility or Company’s Name
Street Suite #
City State Zip Code
Phone # E-Mail
For Office Use Only
Received CK ( ) MO ( ) Number
Revised April, 2020
FORM SA5
I verify that, , a Speech-Language Pathology Assistant
Applicant under my supervision has completed 25 hours of clinical observation and 75 hours of
clinical assisting experience as indicated below:
First Month: Week One from to
Observation Hours Assistance Hours
First Month: Week Two from to
Observation Hours Assistance Hours
First Month: Week Three from to
Observation Hours Assistance Hours
First Month: Week Four from to
Observation Hours Assistance Hours
Second Month: Week Five from to
Observation Hours Assistance Hours
Second Month: Week Six from to
Observation Hours Assistance Hours
Second Month: Week Seven from to
Observation Hours Assistance Hours
Second Month: Week Eight from to
Observation Hours Assistance Hours
Signature of Supervisor Date
Supervisor: (check one of the following)
( ) Holds MD License in Speech-Language Pathology, License #
( ) Holds ASHA CCC-SLP, Certificate #
( ) Holds Licensure in SLP in State of , License #
If the Board does not receive within 90 days, proof of successful completion of the clinical
hours within 60 days, the assistant’s Limited License is void and the assistant will need to
reapply.
FORM SA5
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Received CK ( ) MO ( ) Number
Revised April, 2020
FORM SA6
Maryland Department of Health
Board of Examiners for Audiologists, Hearing Aid Dispensers
and Speech-Language Pathologists
4201 Patterson Avenue, Baltimore, Maryland 21215-2299
Phone 410-764-4725 * Fax 410-358-0273 * TTY/ Maryland Relay Service 1-800-735-2258
Delegation Agreement
A Speech-Language Pathology Assistant or an applicant for licensure as a Speech-Language
Pathology Assistant must file a Delegation Agreement with the Board. A separate agreement must
be filed for each supervising Speech-Language Pathologist under whom the SLP Assistant will be
working. Each Delegation Agreement must be re-filed at the time of license renewal.
Speech-Language Pathology Assistant Information:
Applicant’s Name:
Mailing Address:
Day Phone: Evening Phone:
If licensed as an assistant, Maryland SLP Assistant License Number:
Supervising Speech-Language Pathologist
Name:
Address:
Day Phone: Evening Phone:
Maryland SLP License Number: and/or ASHA Number:
Facility Information (where the SLP Assistant Limited Licensee will be practicing)
Facility Name:
Facility Address:
Contact Person: Phone:
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Received CK ( ) MO ( ) Number
Revised April, 2020
FORM SA6
Will the supervising Speech-Language Pathologist be responsible for the practice of the
SLP Assistant at additional facilities? _ Yes _ _No
If yes, please indicate the additional facilities and their addresses here:
Delegation Agreement
The Speech-Language Pathology Assistant named in this Delegation Agreement is authorized to
assist the supervising Speech-Language Pathologist named in this agreement in the implementation
of speech-language pathology treatment goals and related activities as outlined in the SLP Assistant
Regulations (COMAR 10.41.11) under the direction of the supervising SLP at the above named
facility(ies).
The Supervising Speech-Language Pathologist agrees to supervise the SLP Assistant according to
the standards outlined in the COMAR regulations.
The SLP Assistant agrees to perform only those activities authorized in the COMAR
regulations.
The SLP Assistant agrees to notify the Board if this Delegation Agreement is no longer valid.
Signature of SLP Assistant Date
Signature of Supervising SLP Date
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Received CK ( ) MO ( ) Number
Revised April, 2020
FORM SA7
Maryland Department of Health
Board of Examiners for Audiologists, Hearing Aid Dispensers
and Speech-Language Pathologists
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 30 days before the limited license expiration date.
For Office Use Only
Received CK ( ) MO ( ) Number
Revised April, 2020
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FORM SA7
Maryland Department of Health
Board of Examiners for Audiologists, Hearing Aid Dispensers
and Speech-Language Pathologists
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 following 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
a. Maintains appropriate patient/client relationships
b. Communicates effectively and with sensitivity the needs
of the patient/client, family and caregivers
c. Addresses/considers patient/client and significant others
cultural needs and values _
d. Demonstrates insight into patient/client and caregivers
attitudes and behaviors _
e. Refers patient/client/caregivers/other professionals to the
supervising speech-language pathologist when appropriate _
_ _
_ _ _
_ _ _
_
f. Other:
_ _
2. Criteria: Communicates and interacts effectively with supervisor Yes No
a. Accepts and responds appropriately to constructive criticism
b. Requests assistance from supervisor appropriately
c. Actively participates in interactions with supervisor
d. Other:
II.
Personal Qualities:
Standard: The speech-language pathology assistant demonstrates professional behavior and
confidentiality.
1. Criteria: Demonstrates behaviors of a dependable team member, Yes No
which may include:
a. Arrives punctually to appointments with prepared assignments
b. Submits documentation on time
c. Completes assigned tasks within designated treatment session
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Revised April, 2020
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2. Criteria: Demonstrates appropriate conduct in the work environment,
which may include:
a. Maintains confidentiality of client information at all times _ _
b. Maintains professional appearance for work environment _ _
c. Recognizes own professional limitations and performs
within the boundaries of training and job responsibilities _ _
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
a. Selects and prepares appropriate treatment materials _ _
b. Selects treatment materials based on clients age, needs,
culture and motivation _ _
3. Criteria: Complies with documentation standards
a. Documents treatment plans and protocols accurately,
completely and concisely for the supervising speech-language pathologist _ _
b. Documents client progress and performance to supervisor _ _
c. Signs documents and assures co-signature when required _
d. Prepares and maintains client records, charts, graphs,
objective data as directed by the supervisor _ _
4. Criteria: Provides assistance to the supervising speech-language pathologist
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
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
2. Criteria: Manages screening
a. Reports any difficulties encountered with screening procedures
b. Schedules Screenings
c. Organizes screening materials
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Received CK ( ) MO ( ) Number
Revised April, 2020
3. Criteria: Communicates results to supervising speech-language pathologist
a. Seeks guidance when appropriate
_
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_ _
b. Provides descriptive behavioral observations that contribute to results
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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
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 _ _ _ _
3. Criteria: Demonstrates knowledge of treatment objectives and plan
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
I verify
Speech-Language Pathology Assistant has completed 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
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Received CK ( ) MO ( ) Number
Revised April, 2020
FORM SA8
Department of Health
Board of Examiners for Audiologists, Hearing Aid Dispensers
and Speech-Language Pathologists
4201 Patterson Avenue, Baltimore, Maryland 21215-2299
Phone 410-764-4725 * Fax 410-358-0273 * TTY/ Maryland Relay Service 1-800-735-2258
Affidavit To Be Completed By Licensure Board
This portion of the form is to be completed by the Speech-Language Pathology Assistant:
Please verify licensure certification or registration as a Speech-
Language Pathology Assistant in your State for:
First Name Middle Last Name
Date of Birth Social Security Number
License/Certificate/Registration Number:
This portion of the affidavit is to be completed by the Board:
License/Certificate /Registration Number: Date Issued:
Is License/Certificate/Registration in good standing?
Expiration Date:
Please provide basis for qualifying for license/certificate/registration as a Speech-Language
Pathology Assistant in your state that this person met (e.g. educational requirements, practice
requirements, examination, etc.)
Please attach law and regulations governing Speech-Language Pathology Assistants
for your state.
Has License/Certificate/Registration ever been suspended or revoked? No _ _ Yes _ _
If yes, please explain why or attach additional explanation.
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Received CK ( ) MO ( ) Number
Revised April, 2020
Has License/Certificate/Registration been reinstated?
Has disciplinary action ever been taken against this person? If yes, please explain why
or attach additional explanation.
Is there any derogatory information on file concerning this person? Yes _ _ No _ _
If yes, please explain or attach additional explanation.
Signature Date
Title
State Board of
State of
State Seal Here
FORM SA8
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AGENCY PRIVACY REQUIREMENTS FOR NONCRIMINAL JUSTICE APPLICANTS
Authorized governmental and non-governmental agencies/officials that conduct a national
fingerprint-based criminal history record check on an applicant for a noncriminal justice purpose
(such as employment or a license, immigration or naturalization matter, security clearance, or
adoption) are obligated to ensure the applicant is provided certain notices and that the results of
the check are handled in a manner that protects the applicant’s privacy. All notices must be
provided in writing.
1
These obligations are pursuant to the Privacy Act of 1974, Title 5, United
States Code (U.S.C.), Section 552a, and Title 28, Code of Federal Regulations (CFR), Section 50.12,
among other authorities.
• Officials must ensure that each applicant receives an adequate written FBI Privacy Act
Statement (dated 2013 or later) when the applicant submits his/her fingerprints and
associated personal information.
2
• Officials must advise all applicants in writing that procedures for obtaining a change,
correction, or update of an FBI criminal history record are set forth at 28 CFR 16.34.
Information regarding this process may be found at
https://www.fbi.gov/services/cjis/identity-history-summary-checks
and
https://www.edo.cjis.gov.
• Officials must provide the applicant the opportunity to complete or challenge the accuracy
of the information in the FBI criminal history record.
• Officials should not deny the employment, license, or other benefit based on information in
the FBI criminal history record until the applicant has been afforded a reasonable time to
correct or complete the record or has declined to do so.
• Officials must use the FBI criminal history record for authorized purposes only and cannot
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.
3
The FBI has no objection to officials providing a copy of the applicant’s FBI criminal history
record to the applicant for review and possible challenge when the record was obtained based on
positive fingerprint identification. If agency policy permits, this courtesy will save the applicant the
time and additional FBI fee to obtain his/her record directly from the FBI by following the
procedures found at 28 CFR 16.30 through 16.34. It will also allow the officials to make a more
timely determination of the applicant’s suitability.
Each agency should establish and document the process/procedures it utilizes for how/when it gives
the applicant the FBI Privacy Act Statement, the 28 CFR 50.12 notice, and the opportunity to
correct his/her record. Such documentation will assist State and/or FBI auditors during periodic
compliance reviews on use of FBI criminal history records for noncriminal justice purposes.
Name:
Date:
1
Written notification includes electronic notification, but excludes oral notification.
2
See https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement
3
See 5 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);
28 CFR 20.21(c), 20.33(d), 50.12(b) and 906.2(d).
Updated 11/06/2019
MARYLAND
Department of Health
Larry Hogan, Governor • Boyd K. Rutherford, Lt. Governor • Robert R. Neall, Secretary
BOARD OF EXAMINERS FOR AUDIOLOGISTS, HEARING AID DISPENSERS
&
SPEECH-LANGUAGE PATHOLOGISTS
Jennifer L. Mertes, Board Chair • Candace G. Robinson, Executive Director
Criminal History Records Check - In Maryland
A full Criminal History Records Check is a requirement to obtain a license issued by the
Maryland Board of Examiners for Audiologists, Hearing Aid Dispensers and Speech-Language
Pathologists. This includes all initial licenses, transfers from limited to full licensure, and all
renewal licenses. Each individual only needs to complete the process once for this Board.
These instructions are for individuals who reside in Maryland or reside near Maryland. It
is best to obtain fingerprints in Maryland. If it is not convenient to get fingerprinted in
Maryland please follow the procedure in the Out-of-State instructions.
The Department of Public Safety and Correctional Services, Criminal Justice Information
System (CJIS) oversees Criminal History Records Checks. The criminal history records check is
initiated by the applicant/licensee being fingerprinted.
CJIS Authorization#:
FBI ORI#:
Reason Fingerprinted:
Type of Check:
Electronic Fingerprinting
1600003672
MD920528Z
Audiology license
Hearing Aid Dispenser license
Speech-Language Pathology license
Speech-Language Pathology Assistant license
Governmental Licensing/Certification
It is best to have your fingerprints taken electronically in the State of Maryland.
Electronic fingerprinting is available at CHS-approved private providers, most Maryland MVA
locations and most local law enforcement offices.
Please note that the cost of fingerprinting services from private providers may vary. The total
fee must be paid to the provider and the cost is borne by the applicant for initial licensue and
renewal candidates. Private providers in Maryland do not accept cash or money orders.
For additional information regarding fingerprinting in Maryland please contact CJIS:
4201 Patterson Avenue • Baltimore, Maryland 21215-2299 • Web: health.ma,yland.gov/boardsahs • Tel: 410-764-4725 • Fax: 410-358-0273
via telephone at 410-764-4501; or
via their website at http://www.dpscs.maryland.gov/publicservs/:fingerprint.shtm l.
Applicants for Initial Licensure, Reinstatement, or Reactivation
Effective October 1, 2016 all initial applicants for full or limited licensure in Maryland will be
required to submit :fingerprints. All applicants for reinstatement or reactivation who have not
previously fulfilled this requirement must submit :fingerprints. This is a requirement of the
application process and cannot be waived for any reason. An initial license will not be issued
unless proof of the CHRC is on file with the Board.
Maryland residents and individuals who reside near Maryland may have fingerprints taken prior
to mailing an application to the Board. Maryland residents and individuals who reside near
Maryland must use the pre-filled form specific to this Board (link at end of this document and
also available on this Board ' s Forms page). If an individual is unable to use the pre-filled form
the individual must have the CJIS Authorization number and FBI ORI numbers to ensure that the
required reports are issued to the Board (on the first page of this document and on the Board's
homepage). Please note that these numbers are specific to this Board.
After your fingerprints are taken you will be given a receipt for payment that includes a tracking
number; the tracking number is unique to you. Include a copy of the receipt with the tracking
number when submitting the initial application to the Board. Hand-write the professional license
you are applying for and specify either full license or limited license.
Once the results of the background check are received by the Board the application process will
be completed in accordance to Board regulations and policies.
Renewal Applicants
Individuals who obtained a full license before October 1, 2016 will be required to submit
evidence of the CHRC to the Board prior to the issuance of a renewal license. Additional
information has been provided to renewal applicants via e-mail.
General Information
Pursuant to federal law a criminal history records check is only effective for one purpose.
Accordingly, any prior fingerprinting and criminal history records check was only good for the
educational institution, employer, licensing entity, etc. that it was completed for.
When getting fingerprinted please ensure the following:
that the fingerprint operator spells your name correctly; and
that the proper OIR and authorization numbers are used.
A list of private providers that have electronic fingerprinting services are provided on the State
of Maryland's Department of Public Safety & Correctional Services website. Click below for
immediate access to fingerprinting locations in Maryland. Call ahead to make sure the
provider is open and has the October 1, 2016 software update.
https://www.dpscs.state.md.us/publicservs/fingerprint.shtrnl
Print LiveScan Pre-Registration Application
https://health.maryland.gov/boardsahs/DocumentsaudLiveScan.pdf
All applicants must print the LiveScan Pre-Registration Application and take it to the
fingerprinting location in Maryland.
Please
do not
call the Board's offices for an update on a background check. The background
check is completed by a separate state agency. The Board has no control over the amount of time
it takes to complete the check. If you have not received the results of the criminal history
background check after thirty days, you may contact CJIS directly at 410-764-4501.
Please refer to§ 2-303.1 Criminal History Record Checks of the Maryland Board of Examiners
for Audiologists, Hearing Aid Dispensers and Speech-Language Pathologists for a full
description of the requirements.
STATE OF MARYLAND
DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES
CRIMINAL JUSTICE INFORMATION SYSTEMS – CENTRAL REPOSITORY
LIVESCAN PRE-REGISTRATION APPLICATION
APPLICANT INFORMATION
(PLEASE TYPE OR PRINT CLEARLY)
Name:
Date of birth:
SSN:
Gender: Male Female
(Please check)
Height: ft. inches Weight:
lbs. Eye Color: Hair Color:
Race:
Black
White
)
Asian/Pacific Islander
Native American Other
(Please check)
Place of Birth: Citizenship:
Current address:
City:
State:
ZIP Code: -
Daytime Phone: Evening Phone: Driver’s License #:
AGENCY INFORMATION
Agency Authorization #: 1600003672
ORI # (if required): MD920528Z
Reason fingerprinted? Licensing
Position Applied for: Board of AUD HAD and SLP
Request Type:
(Choose one ONLY)
Adult Dependent Care
Attorney/Client
Child care
Criminal Justice
Gold Seal/ Adoption
Gold Seal/Letter/VISA
Government Employment
Government Licensing or Certification
Immigration/VISA
Individual Challenge
Individual Review
MSP Licensing
Private Party Petition
Public Housing
Mail Response to:
(Mailing option only available for Visa Gold Seal and/or Individual Review)
Name: Do Not Mail This Form To The Board
_
Address: Do Not Mail This Form To The Board
_
City, State, Zip code: Do Not Mail This Form To The Board
MARYLAND
Department of Health
Larry Hogan, Governor • Boyd K. Rutherford, Lt. Governor • Robert R. Neall, Secretary
BOARD OF EXAMINERS FOR AUDIOLOGISTS, HEARING AID DISPENSERS
& SPEECH-LANGUAGE PATHOLOGISTS
Jennifer L. Mertes, Board Chair • Candace G. Robinson, Executive Director
Criminal History Records Check - Out of State Applicants
A full Criminal History Records Check is a requirement to obtain a license issued by the Maryland
Board of Examiners for Audiologists, Hearing Aid Dispensers and Speech-Language Pathologists.
This includes all initial licenses, transfers from limited to full licensure, and all renewal licenses
(including reinstatement of a license or reactivation of a license). Each individual only needs to
complete the process once for this Board.
These instructions are for individuals who reside outside of Maryland where it is
inconvenient to come to Maryland to complete the fingerprinting process. Please note that it
is best to obtain fingerprints in Maryland. If fingerprints are able to be completed in
Maryland please follow the procedure in the In-State instructions.
The Department of Public Safety and Correctional Services, Criminal Justice Information System
(CJIS) oversees Criminal History Records Checks. The record checks are conducted by the
applicant/licensee being fingerprinted.
CJIS Authorization #:
FBI ORI#:
Reason Fingerprinted:
Type of Check:
1600003672
MD920528Z
Audiology license
Hearing Aid Dispenser license
Speech-Language Pathology license
Speech-Language Pathology Assistant license
Governmental Licensing/Certification
In order to comply with the Criminal History Records Check requirement and to not delay the
issuance of a license, please abide by these instructions. Please note that it may take up to five
weeks for CJIS to issue the required reports to the Board.
Out-of-state residents may use a location outside the State of Maryland, but must use the CJIS
fingerprint card that has pre-printed Board-specific information.
Call the Board at 410-764-4725 to request a fingerprint card.
Applicants
for an initial license
should request a fingerprint card at least six weeks in advance of the anticipated date that licensure
is required. License renewal candidates should request a fingerprint card no later than April 15,
4201 Patterson Avenue •Baltimore.Maryland 21215-2299 • Web: health.maryland.govlboardsahs • Tel: 410-764-4725 • Fax: 410-358-0273
2018 to ensure sufficient time to complete the process and complete the online renewal process.
These timeframes assume an individual mails the fingerprint card to Maryland CJIS within a week
of receiving the fingerprint card and having the fingerprints taken.
Once the fingerprint process is complete you must mail the fingerprint card to the following
address with a check for $31.25 payable to the "CJIS Central Repository."
CJIS Central Repository
PO Box 32708
Pikesville, MD 21282-2708
Make a copy of the receipt with the tracking number that was issued to you. Legibly write
your full name and profession on the copy being mailed to the Board (may be included
with the application for licensure). Mail a copy of the receipt for fingerprinting to:
Maryland Board of AUD HAD SLP
ATTN: Background Check
4201 Patterson Avenue, 3rd Floor
Baltimore, MD 21215
For applicants for initial licensure: Once the results of the background check are received
the application process will be completed in accordance with Board regulations and
policies.
For renewal applicants: Once the results of the background check are received the Board
will make the necessary changes to allow access to the online renewal process within 48
hours (notice will be provided via e-mail).
For additional information contact CJIS:
via telephone at 410-764-4501; or
via their website at http://www.dpscs.maryland.gov /publicserv s/fingerprint.shtml.
Effective October 1, 2016
Every new applicant submitting an application on or after October 1, 2016 for a license
issued by the Board must submit a criminal history records check (CHRC) to the Board.
This includes license reinstatement and license reactivation when this requirement has not
previously been fulfilled.
This is a requirement of the application process and it is a one-time requirement. All fees
associated with the criminal history records check requirement must be borne by the
applicant/licensee.
A license will not be issued unless proof of the CHRC is on file with the Board.
Individuals with an incomplete application as of October 1, 2016, with the Board must
submit a CHRC to the Board. This is a requirement prior to the issuance of a license.
Individuals holding a full license on or after October 1, 2016 will be required to submit
evidence of the CHRC to the Board prior to the issuance of a renewal license.
Please
do not
call the Board's offices for an update on a background check. The background
check is completed by a separate state agency. The Board has no control over the amount of time
it takes to complete the check. If you have not received the results of the criminal history
background check after thirty days, you may contact CJIS directly at 410- 764-4501.
Please refer to
§ 2-303.1 Criminal History Record Checks of the Maryland Board of Examiners
for Audiologists, Hearing Aid Dispensers and Speech-Language Pathologists for a full description
of the requirements.
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Completed 21 January 2022

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