Fillable Record Keeping Form for Certification Maintenance Audit (Not (American Speech-Language-Hearing Association)

Fill Online, Printable, Fillable, Blank Record Keeping Form for Certification Maintenance Audit (Not (American Speech-Language-Hearing Association) Form

Use Fill to complete blank online AMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Record Keeping Form for Certification Maintenance Audit (Not (American Speech-Language-Hearing Association)

On average this form takes 16 minutes to complete

The Record Keeping Form for Certification Maintenance Audit (Not (American Speech-Language-Hearing Association) form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 65 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your American Speech-Language-Hearing Association forms online.

BROWSE AMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION 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
 
Record Keeping Form for Certification Maintenance Audit
(Not Current Certificate Holders in 2017-2019 Interval Only)
Instructions
You must submit a Certification Maintenance Compliance Form (Not Current Certificates Holders Only) with this form.
Complete and submit this form only if you are Not Current and overdue on your 2017-2019 certification maintenance interval requirements.
List each of your professional development activities on a separate line. You do not need to provide certificates of completion/attendance with this
form.
Submit form by one of the following: *Mail: ASHA
2200 Research Blvd. #313
*E-mail: cccmaintenance@asha.org Rockville, MD 20850
Name: _____________________________________ ASHA ID#: __________ Area(s) of Certification CCC-A CCC-SLP Dual
*ASHA Certification Maintenance Hour (CMH) = 1 clock hour/60 minutes spent in a professional development activity as a learner or participant.
0.1 ASHA CEU = 1 CMH 0.15 ASHA CEU = 1.5 CMHs 3.0 ASHA CEUs = 30 CMHs 1 semester hour of academic coursework = 15 CMHs
Title of Activity Completion
Date
Sponsoring Organization/
Third Party
Number of
CMHs
*
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

Record Keeping Form for Certification Maintenance Audit (Not (American Speech-Language-Hearing Association)

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 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document