Fillable Speech-Language Pathologist Full License Application Checklist & Application (State of Maryland)

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Speech-Language Pathologist Full License Application Checklist & Application (State of Maryland)

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The Speech-Language Pathologist Full License Application Checklist & Application (State of Maryland) form is 24 pages long and contains:

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  • 36 check-boxes
  • 211 other fields

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I.
All applications require the following items be received at the Board office, in addition to the
items in either section II or III, before the application is complete and ready for Board approval:
If Applicant Currently Holds ASHA-Issued Certificate of Clinical Competency:
Primary Source Verification Letter from ASHA confirming current with CCC-SLP
Brief Resume (if applicant has been practicing more than 5 years)
While we will accept electronic documents sent in the form of a scanned
pdf (phone screenshots are not acceptable) to help expedite the licensing
process, we will NOT accept ANY documents without original
signatures and notarizations. Documents without original signatures
and/or notarizations will be considered incomplete and the application
will not be approved. Original documents of any electronic pdf
submissions, must ALSO be sent to the Board office within 30 days of
the issuance of a license. Please upload your application with
supporting documents using our online application. If you have any
question please email monicah.wright@maryland.gov.
Signed and Notarized Application
Speech-Language Pathologist –
Full License Application Checklist & Application
PLEASE NOTE:
$150.00 Fee (check or money order payable to the Board of SLP)
A recent 2x2 passport size photo
Criminal History Records Check (must be received by CJIS before a license can be issued)
Completed Law and Regulation Examination (requires a passing score of 75% or greater)
II.
Additional documents to be submitted:
License affidavit from all states in which the applicant is currently licensed or has ever
been licensed
If Applicant Does Not Hold ASHA-Issued Certificate of Clinical Competency:
Official Speech-Language Pathology Master’s Degree Transcript
Praxis Exam Scores (successfully completed within the past 5 years)
Clinical Fellowship Year Plan (Form AS2)
Clinical Fellowship Year Verification (Form AS3)
Revised February, 2021
_
_ _ $150 Fee (check or money order payable to the Board of SLP) AND:
III.
Applicants who currently hold an active Maryland Limited License in Speech-Language
Pathology ONLY need to Submit the Following once the Clinical Fellowship Year (CFY) is
complete (a new Speech-Language Pathology application is NOT needed):
_ _ EITHER of the following two options:
Option A - AS3 form for verification of completion of the clinical fellowship year AND
Passing score on the Praxis examination sent directly to the Board by ETS. An official
Master’s Degree transcript sent directly to the Board by the school from which the degree
was conferred (this should have been submitted within 60 days of your limited license).
Option B – Primary Source Verification of holding the CCC-SLP sent directly to the Board
from the American-Speech-Language-Hearing Association (ASHA)
Note: Law and Regulations Examination
To pass the open book examination, all applicants must score at least 75. You can
download the examination from the Board’s web site at
https://health.maryland.gov/boardsahs/.
Use the Forms Link to download and print a copy of the law examination. To complete the
examination, refer to the law and regulation reference number included with the question. Use
the “Laws (Statutes) & Regulations” link on the Board’s web site (left side of the landing page)
to access the laws and regulations to answer the questions. Once in the “Laws and Regulations”
section, the Laws are accessible through the link at the top of the page and the regulations
(COMAR) are accessible through the link at the bottom of the page. A license will not be
issued unless the Law and Regulation Examination is passed.
Note: Criminal History Records Check
Effective October 1, 2016 an applicant for initial licensure must submit evidence to the Board
of an application for a criminal history records check (CHRC).
Information and forms regarding the required CHRC is on the Board’s Forms page (click on
Forms in the Quick Links section).
An application for licensure will not be processed until the application is complete,
including submitting evidence of a criminal history records fingerprint receipt.
All applicants should download, fill out, and print the Board’s pre-filled LiveScan Pre-
Registration Form. The form has relevant Board-specific information already on the form.
This form must be presented to the fingerprinting service.
Application forms can be found on the CHRC resources page on the Board’s website, by clicking
on the “Forms” link. Once you are in the “Forms” section, you will see the information there.
Revised February, 2021
In-state applicants and out-of-state applicants near Maryland may go to an authorized
fingerprinting location in Maryland. The CHRC resources page on the Board’s website provides a
link to the Department of Public Safety & Correctional Services’ list of authorized fingerprinting
locations.
Out-of-state applicants must contact the Board’s administrative assistant to provide the name and
address of where to send the fingerprint card. Applicants may call 410-764-4725 or email
monicah.wright@maryland.gov, to request and provide their information. Official out-of-state
fingerprint cards may be mailed directly to the applicant before submission of an application for
licensure to this Board.
Please note that the CHRC requirement is in addition to answering the disciplinary
questions in the application and a license cannot be issued until the CHRC requirement
has been satisfied.
TOEFL Scores
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.
Continuing Education Requirement Notice
Continuing education is a requirement to renew a license. Continuing is prorated for most
new licensees depending on the issuance date of the full license. Information regarding the
amount of continuing education required to renew the license is issued to new licensees.
The continuing education requirement for renewing a speech-language pathology license is
30.0 hours (clock hours) or 3.0 CEUs, completed during two calendar years ending on
December 31
st
of the year preceding the expiration date of the license. For example, a license
expiring on May 31
st
, 2020, requires that 30 hours or 3.0 CEUs be completed between
1/1/2018-12/31/2019, for the June 1, 2020 renewal.
Revised February, 2021
If yes, License # Date Expired
If yes, please provide detailed explanation on a separate sheet of paper and attach it to the
application as well as court documentation.
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
Speech-Language Pathologist Full License Application
Date
II. Affix current
2x2 passport size photo
*****Please refer to the Speech-Language Pathologist Full License Application Checklist included with this
application, to ensure proper completion of either a speech-language pathology limited license converting to
full license, or a first time speech-language pathology full license applicant*****
I. Name
Last First Middle/Maiden
Home Address
Street Apt.
City State Zip Code
Home Phone Alternate # Email
Date of Birth Social Security #
Other____________________________ What is your first language? English
Have you previously been licensed in the State of Maryland? Yes No
Have you ever been convicted of a felony or a misdemeanor involving moral turpitude?
No Yes
II. Education
Graduate School
Address
Street City State Zip Code
Attended to Major Date Degree Awarded _
For Office Use Only
CHRC
Revised January, 2021 CH ( ) MO ( ) Number_____ Received______
_______
_____
Undergraduate School
Address
Street City State Zip Code
Attended to Major Date Degree Awarded
III. Do you currently hold the American Speech-Language Hearing Association Certificate of
Clinical Competence in Speech-Language Pathology? _ _Yes _ _No
If Yes, date originally granted **
• Clinical Fellowship Year completed? Yes No
• Praxis Examination in Speech-Language Pathology Passed? Yes No
If No, the applicant must submit Praxis scores showing successful completion within 5 years of
submission of this application, the AS2 and AS3 Forms with original signatures, and, an official
transcript showing a conferred Master’s degree in Speech-Language Pathology from an
accredited program, sent directly from the graduate institution to the Board.
OR
If No, and the applicant previously held the ASHA CCC-SLP, an official letter from ASHA
indicating when the CCC-SLP was earned and when it expired, must be submitted along with
this application. The Board will determine whether or not they will grant the license once in
receipt of this letter from ASHA, along with an otherwise completed application.
**If you answer “no” to III. above, OR, if your CCC-SLP was granted more than 5 years ago,
please also enclose a professional resume and proceed to IV. below. **
IV. Employment during Clinical Fellowship Year – must submit a Form AS2 and AS3
for each place of employment during the period of limited licensure.**
Facility/Company Name
Address
Street City State Zip Code
Brief description of duties
Revised February, 2021
Are you now or have you ever been licensed in any other state? If yes, please
complete the first page of the Licensure Affidavit ( AS4). Request the State licensure Board
to return the completed form to the Maryland Board office.
I am licensed in the following states
I was licensed in the following states _
VI. Has any disciplinary action ever been taken against any license you have held in any
other jurisdiction?
No Yes
If yes, please provide a detailed explain on a separate sheet attached to this application.
VII. Have this Affidavit completed by a Notary Public
I hereby affirm that I have read Sections 2-101 to 2-502 of Title 2 of the Health Occupations
Article of the Annotated Code of Maryland and fully understand that in receiving a license from
the Board, I bind myself to be governed by the Board.
I understanding that in submitting this application that the accompanying fee is for
administrative purposes and is not refundable. The fee includes licensure fee.
State of City/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 ifnecessary.
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.
Revised February, 2021
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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
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 Full
Revised February, 2021
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 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?
Form AS2
Revised October, 2020
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 October, 2020
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(
(
(
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 Satisfactory Completion of
Speech-Language Pathologist Clinical Fellowship Year
I hereby declare that
Name of Applicant
of
Street City State Zip Code
an applicant for Maryland licensure in speech-language pathology, was employed as a
professional in that field from to for _ hours per week.
mm/dd/yyy mm/dd/yyyy
The place of employment was
Facility Name
Address City State Zip Code
I further declare that the applicant was supervised by
Name of Supervisor
At that time the CFY supervisor held (must be at least one of the following):
Maryland License in Speech-Language Pathology License #
ASHA Certification in Speech-Language Pathology Certificate #
A License in Speech-Language Pathology from the State of
from which licensure requirements were equivalent to ASHA certification.
I verify that during the employment period, the applicant reached a satisfactory level of
competence in the area in which licensure is sought.
Signature of Supervisor
Typed or Printed Name
Title
Date
Form AS3 Revised January, 2021
Current Phone Number
Licensure Board Affidavit
This section is to be completed by the speech-language pathologist applying for a
Maryland license.
First Name Middle Name Last Name
Date of Birth Social Security Number
Graduate of Date
*****************************************************************************
This portion of the affidavit is to be completed by the Licensure Board you are
requesting verification from.
**Please verify the license of the above applicant in your state of jurisdiction**
State License # Date Issued
With State Examination Without Examination
Is license in good standing? Expiration Date
Has the license ever been suspended or revoked? If yes, please explain why:
Attach a separate sheet
Has the license been reinstated?
Has any disciplinary action been taken against the licensee? If yes, please explain:
Is there any derogatory information on file concerning this licensee?
explain:
If yes, please
Signature Date
Title
Form AS4
Revised January,2021
Affix Board
Seal Here
NOTES:
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
.
R
o
b
inson, 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.
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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
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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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Speech-Language Pathologist Full License Application Checklist & Application (State of Maryland)

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Completed 11 January 2022

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