Fillable RESPONSIBILITY STATEMENT FOR SUPERVISORS OF A SPEECH-LANGUAGE PATHOLOGY (California)

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RESPONSIBILITY STATEMENT FOR SUPERVISORS OF A SPEECH-LANGUAGE PATHOLOGY (California)

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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
PHONE (916) 287-7915 WWW.SPEECHANDHEARING.CA.GOV
RESPONSIBILITY STATEMENT FOR SUPERVISORS OF A
SPEECH-LANGUAGE PATHOLOGY ASSISTANT
INSTRUCTIONS: Complete the following sections; read the statements and sign on page 2. This form must be
submitted within 14 business days from the start date of supervision. Do not use white out or fax this form.
PART A: SPEECH-LANGUAGE PATHOLOGY ASSISTANT INFORMATION
1. FULL LEGAL NAME: LAST FIRST MIDDLE
2. SPEECH-LANGUAGE PATHOLOGY ASSISTANT LICENSE NUMBER
3. STREET ADDRESS:
CITY
, STAT
E, ZIP CODE:
4. EMAIL ADDRESS:
PART B: SUPERVISOR INFORMATION
1. FULL LEGAL NAME OF SUPERVISOR: LAST FIRST MIDDLE
2. SPEECH-LANGUAGE PATHOLOGY LICENSE NUMBER OR CLEAR CREDENTIAL ISSUE DATE
3. STREET ADDRESS:
CITY, STA
TE, ZI
P CODE:
4. EMAIL ADDRESS:
Refer to Title 16, California Code of Regulations, Section 1399.170.15 for supervisor’s responsibilities.
PART C: SUPERVISION
5. DATE SUPERVISION BEGAN: (MM/DD/YY)
6. ARE YOU SUPERVISING AN ASSISTANT WHO HAS MORE THAN ONE SUPERVISOR? YES NO
If yes, please indicate whether you will be the supervisor designated as the lead supervisor for the purposes of assisting the
speech-language pathology assistant in his or her compliance with the continuing professional development requirement pursuant
to section 1399.170.17 of the California Code of Regulations. YES NO
[SPA 110/REV 01/16] Page 1 of 3
SPEECH-LANGUAGE PATHOLOGY ASSISTANT
Duties and Responsibilities of Speech-Language Pathology Assistant
Division 13.4 of Title 16, California Code of Regulations Section 1399.170.15 requires that any qualified speech-language
pathologist who assumes responsibility for providing supervision to a registered speech-language pathology assistant to
complete and sign under penalty of perjury, the following statement.
1) I have re
ad and understand the excerpts of the laws and regulations, included with my application, pertaining to th
e
responsibilities of a Speech-Language P
athology Assi
stant.
2)
My
supervisor shall maintain a current license issued by the Board, during the time of my supervision. If m
y
sup
ervisor’s license expires during the course of professional experience, I will immediately notify the board.
A
sup
ervisor’s license can be verified at any time at the Board’s webs
ite.
A
PPLICANT SIGNATURE PRINTED NAME OF APPLICANT DATE
Duties and Responsibilities of Supervisor
Division 13.4 of Title 16, California Code of Regulations Section 1399.170.15 requires that any qualified speech-language
pathologist who assumes responsibility for providing supervision to a registered speech-language pathology assistant to
complete and sign under penalty of perjury, the following statement.
1) I possess the
following qualification to supervise an aide applicant: a current valid Speech-Language Path
ology
licen
se issued by the Board; or (if employed by a public school) a valid, current , and professional clear cred
ential
authorizing service in language, speech, and hearing issued by the Commission on Teacher Credentialing.
2)
I agree to en
sure that either my California licensee or my clear credential is renewed in a timely
manner.
3)
I will immediately notify
the assistant of any disciplinary action, including revocation, suspension (even if st
ayed),
probation terms, inactive license, or
lapse in licensure that affects my
ability or right to supervise.
4)
I will maintain records of course completion for a period of two years from the assistant registration renewal date.
5)
I will complet
e no less than six (6) hours of continuing a professional development in supervision training in
the initial
two year pe
riod from the commencement of supervision, and three (3) hours in supervision trai
ning every two years
thereafte
r pursuant to Section 1399.170.15(b)(4) of the California Code of Regul
ations.
6)
I have read a
nd understand the laws and regulations pertaining to the supervision of assistants and the experien
ce
requi
red for registration as an assistan
t.
7)
I will ensu
re that the extent, kind, and quality of the clinical work performed are consistent with the training a
nd
experie
nce of the assistant and shall be accountable for the assigned tasks performed by the assistan
t.
8)
I will review cl
ient/patient records, monitor and evaluate assessment and treatment decisions of the assistan
t, monitor
and evalu
ate the ability of the assistant to provide services at the site(s) where he or she will be practicing a
nd to the
particula
r clientele being treated, and ensure compliance with all laws and regulations governing the practi
ce of
spe
ech-language pathology
.
9)
I will assi
st with the development of a plan for the assistant to complete twelve (12) hours of continuing prof
essional
developm
ent every two years, through state or regional conferences, workshops, formal in-service presenta
tions,
indep
endent study programs, or any combination of these, concerning communication disord
ers.
10)
I will discuss with the assistant the manner in whic
h emergencies will be handled.
[SPA 110/REV 7/15] Page 2 of 3
Duties and Responsibilities of Supervisor
cont’d
11) I will provide this Board with this original signed form within 14 calendar days of commencement of any supervision. I
will provide a copy of this form to the assistant.
12) Upon written request of the Board, I will provide to the Board any documentation, which verifies my compliance
with
the requi
rements set forth in this statem
ent.
13)
I will not supervise more than three (3) support personnel, not more than two of which hold the title of Speech-
Language Pathology Assi
stant.
14)
At the time of termination of supervision, I will complete the “Termination of Supervision” form 77ST(new 12/
99). I will
submit the o
riginal signed form to the Board within fourteen (14) calendar days of termination of supervi
sion.
SIGNATURE OF SUPERVISOR PRINT FULL LEGAL NAME OF SUPERVISOR
LICENSE NUMBER OR CREDENTIAL NUMBER DATE
(Please attach a copy of the front and back of your credential)
[SPA 110/REV 7/15] Page 3 of 3
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RESPONSIBILITY STATEMENT FOR SUPERVISORS OF A SPEECH-LANGUAGE PATHOLOGY (California)

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Completed 2 November 2021

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