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

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

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September, 2020
Speech-Language Pathologist – Limited License
Application Checklist
Please read all instructions on this checklist before completing and submitting this application.
Print legibly on application and Law and Regulation Examination.
I. All Applicants Must Submit:
____ $100.00 Fee (make check or money order payable: Board of SLP)
____ A recent 2x2 passport size color photo
____ Signed and Notarized Application
____ Completed Law and Regulation Examination (see note)
____ Proof of Fingerprinting for Criminal History Records Check
Note: The Law and Regulation Examination is an open book examination. An applicant must
score at least 75 percent on the Examination. Applicants can download the examination from the
Board’s web site at https://health.maryland.gov/boardsahs/Pages/Index.aspx. Use the Forms
Link to download a copy of the law examination. To complete the examination, refer to the law
and regulation reference number included with the questions. Use the “Statute and Regulations”
link underneath the Regulations heading on the left side of the Board’s web site to access the
laws and regulations to answer the questions. A license will not be issued unless the Law and
Regulation Examination has been successfully passed. Submit the Law and Regulation
Examination with the main application.
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 Menu section).
An application for licensure will not be processed until the application is complete,
including submitting evidence of a criminal history records fingerprint receipt, and the
required CJIS-issued reports have been received by the Board.
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 form found on the Forms page under the Menu on the Board’s website.
In-state applicants and out-of-state applicants near Maryland may go to an authorized
fingerprinting location in Maryland. The Forms 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 at 410-764-4725 to request an official out-
of-state fingerprint card and instructions to be mailed directly to the applicant before
submission of an application for licensure to this Board. The CHRC requirement is in
addition to answering the disciplinary questions in the application.
II. All Applicants Must Submit the Following Documents:
____Official Master’s Transcript:
Official transcript must show degree conferred date.
For new graduates the Board will accept a letter from the Department Chair stating that
applicant has completed all coursework and clinical practicum if transcript does not
yet show the degree as having been awarded. The Department Chair letter must also
include the date that the degree will be conferred and the school’s accrediting body
and status by CAA or ACAE. The conferred date must be before the date that an
application is approved by the Board. If the degree has not been conferred yet at
the time of the Board meeting, it will not be approved until after the degree has
been conferred at the next Board meeting. An applicant obtaining a limited license
via Department Chair letter must request from the educational institution the official
transcript directly to the Board – the official transcript is due to the Board no later than
60 days after the imited license has been issued. Undergraduate transcripts do not
need to be submitted to the Board.
____ Clinical Fellowship Year Plan (Form AS2)
Note: A supervisor must be a licensed speech-language pathologist in the State of
Maryland or if the supervisor is exempt from the licensure requirements the supervisor
must hold the ASHA Certificate of Clinical Competency.
Note: A Form AS2, Verification of Supervision for Limited Licensure/
Clinical Fellowship Year, must be submitted for each supervisor during the period
of limited licensure and for any change in the number of hours practicing per week.
Note: Applicants for a limited license who have completed some of the required nine
months of supervised practice in another state must submit a Form AS2 and a Form AS3
completed by their supervisor in the other state to obtain credit for supervised practice
in that state.
Application Processing
Applications are processed continuously in the order received at the Board office. Applications
are only forwarded for Board approval wh
en complete. Complete applications include proof of
fingerprinting for the required criminal history records check and both the Maryland and FBI
required CJIS-issued reports having been received by the Board. Please note, that CJIS will not
discuss any fingerprint report statuses with anyone but the applicant.
Some applications for limited licensure require Board-approval. These applications are
processed after the Board has voted and made a decision at a Board meeting.
There is no expediting of the approval of applications under any circumstances.
Applications must be approved by the Board at monthly Board meetings. Applications should
be received at the Board office one week prior to the next Board meeting, for the best chance to
be reviewed for completion or they may not be approved until the following Board meeting.
Notice of Administrative Closure of Application: Pursuant to COMAR 10.41.03.08 the Board
may administratively close an application if the application remains incomplete one year after
the application was received.
September, 2020
Requirements for Clinical Fellowship Year (CFY)
CFY Time Requirements:
The CFY must be started within two years after completion of the academic coursework and
clinical practicum requirements and must then be completed within 24 months., unless
extenuating circumstances have not permitted an applicant to do so, and are approved by the
Board. The CFY can be completed either by full-time or part-time professional employment.
See the requirements on this sheet for full-time or part-time professional employment to
meet the supervised practice requirement.
Full-Time Requirement Is As Follows:
30 or more hours per week for a minimum of 9 months
Part-Time Requirements Are As Follows:
15-19 hours per week – must work a minimum of 18 months
20-24 hours per week – must work a minimum of 15 months
25-29 hours per week – must work a minimum of 12 months
At least 80% of the CFY work must be in direct client contact which includes
assessment/diagnosis/evaluation, screening, habilitation/rehabilitation, and activities
related to client management.
The Board will not approve a CFY of less than 15 hours per week.
Form AS2:
An applicant for a Limited License shall submit a Form AS2, Verification of Supervision for
Limited License Clinical Fellowship Year, with the application to the Board. The applicant
may not begin practicing until the Limited License Application is approved by the Board
and the license has been issued. A Limited License authorizes the applicant to practice only in
the setting and under the supervision of the person specified on the Form AS2.
A change in supervisor and/or employment requires Board approval prior to the limited licensee
beginning to practice under the new supervisor. The limited licensee and the new supervisor
must submit a new Form AS2 to the Board for review.
CFY Supervision Requirements:
The supervisor shall provide a minimum of 36 hours of supervisory activities during the clinical
fellowship year. Additionally, a minimum of two hours of other monitoring activities each
month are to be provided by the supervisor.
National Examination Score Report:
The Limited Licensee must request a copy of the National Examination, the Praxis Exam, to be
sent to the Board.
September, 2020
Applicants for a limited license in speech-language pathology are strongly encouraged to contact
ETS to ensure that the Board can view Praxis score reports via the ETS’ score reporting system.
A copy of the Praxis exam score report is not required to obtain a limited license, but it is
required to be on file to transfer the limited license to a full license when the supervised practice
requirement has been met.
Renewal of Limited License as a Speech-Language Pathologist
If an individual that holds a limited license as a speech-language pathologist is unable to obtain
at least 9 months of supervised practice as a full-time limited licensee or obtain the specified
months of supervised practice as a part-time limited licensee the individual may renew the
limited license for an additional year.
The limited license renewal form and the $25.00 renewal fee must be submitted at least 30 days
prior to the expiration of the limited license. An individual with a renewed limited license is
eligible for transfer to a full license provided the minimum number of supervised months has
been completed prior to the expiration date of the second year of limited licensure.
If an individual fails to obtain the minimum of 9 months of supervision within the two years of
limited licensure the individual must wait an additional year after the expiration of the renewed
limited license before the individual can reapply for a limited license as a speech-language
pathologist.
Transfer of Limited License to Full License
Upon completion of the CFY (i.e., nine months of supervised practice), the Limited Licensee
shall submit to the Board a Form AS3, Verification of Satisfactory Completion of CFY,
completed by the supervisor. If the CFY was conducted in more than one setting, or under more
than one supervisor, a separate Form AS3 must be submitted for each setting or supervisor.
An individual holding a limited license as a speech-language pathologist will be transferred to a
full license provided the individual has met all the licensure requirements, the application is
complete, and the limited licensee has been supervised for at least 9 months. The Form AS3
must be received by the Board no sooner than the 9 months of supervised practice ends and no
later than 30 days prior to expiration of the limited license.
The Limited Licensee must ensure that the Board has a copy of the Praxis Examination scores.
Transfer of a limited license to a full license does not require submission of any other documents
provided the licensure file is complete and the limited license is still valid and unexpired. A $150
fee made payable to the Board of Examiners for AHS is required to complete the application for
full licensure.
The expiration date of an initial full license will be May 31st of the following year.
Continuing Education
Continuing education is a requirement to renew a full license. The continuing education
requirement 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 via e-mail and is posted to the Board’s website.
September, 2020
September, 2020
The continuing education requirement for renewing a speech-language pathology license that has
already been renewed once, is 30 hours
or 3.0 CEUs (.1 CEUs = 1 hour of CEUs). The
continuing education cycle is not concurrent with the license cycle. The continuing
education cycle is the two calendar years preceding the expiration date of the license through to
December 31st. For example, if your license expires on 5/31/2020, in order to renew your license
you must submit evidence of 30 hours of continuing education completed between 1/1/2018 and
12/31/2019 for the 2020 renewal.
Continuing education is not required to renew a limited license.
Applicants are advised to do the following:
Keep a copy of this application checklist.
Print a copy of the application for your records.
Provide an e-mail address on the application that is a frequently checked account.
Submit an application form currently in use by the Board.
Applicants are strongly advised the following:
Do not fax the application to the Board.
Do not increase or reduce the size of the application in any manner.
Do not use white-out on the application.
Revised October, 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 a
Limited License as a Speech-Language Pathologist
Please Read The Application Checklist Before Completing Application Below:
1. Name
Last First Middle/Maiden
2. Home Address
Street Apt.
City State Zip Code
3. Home Phone Alternate #
Email
4. Date of Birth Social Security #
5. Have you previously been licensed in the State of Maryland? If yes,
License # Date Expired
6. Have you ever pled guilty, nolo contendere, or been convicted of or received probation before
judgment of any criminal act (excluding minor traffic violations)? No Yes
If “Yes” you must submit (1) a complete explanation discussing your case(s), subsequent
employment, rehabilitation, and/or good conduct, if any, and (2) certified copies of your court
documents showing the outcome and underlying facts and circumstances of your case(s) must be
submitted for review.
FOR OFFICE USE ONLY
Received _ CHRC Complete
CH ( ) MO ( ) Number Date
Affix current
2x2 passport
size photo
Revised October, 2020
7. Education
Graduate School
Address
Street City State Zip Code
Attended to Major Date Degree Conferred
Undergraduate School
Address
Street City State Zip Code
Attended to Major Date Degree Awarded
8. Department Chair Letter In Lieu of Official Transcript (for recent graduates)
This section is to be completed by applicants that are recent graduates (up to 60 days after
graduation) that are submitting proof of the education requirements with a letter issued by the
Department Chair. Department Chair letter must include a statement that the student has
completed all coursework and all clinical requirements, the degree conferred date, and the
institution’s accreditation.
I hereby affirm that I have read Section 2-310.2 of Title 2 of the Health Occupations Article of
the Annotated Code of Maryland and Code of Maryland Regulations 10.41.03.03A(2)(a) and that
I understand a Master’s degree in speech-language pathology is the minimum educational
requirement to hold a limited license in speech-language pathology. I hereby agree that I am
solely responsible for ensuring that the Board receives an official transcript of my Master’s
degree within 60 days of the issuance of the limited license. I hereby affirm that I will be subject
to the grounds for discipline, specifically Section 2-314(10) “Commits any unprofessional act in
the practice of … speech-language pathology.” if the Board does not receive an official transcript
within 60 days of the issuance of a limited license.
Signature of Applicant Printed Name of Applicant
Revised October, 2020
9. Employment for Clinical Fellowship Year
Date Title of Position
Facility/Company Name
Address
Street City State Zip Code
Brief description of duties during clinical fellowship year:
10. Continuing Education Required to Renew A Full License
This section is to be completed by applicants who are applying for a limited license in speech-
language pathology.
I hereby affirm that I understand that pursuant to COMAR 10.41.03.06 the Board has
established continuing education requirements to renew a full speech-language pathology
license.
I hereby affirm that I understand that the continuing education requirements supersede
any private professional association’s requirements to maintain a certification or similar
title.
I further affirm that I understand that completing continuing education is not a
requirement to hold a limited license in speech-language pathology or to renew a limited
license in speech-language pathology. However, I affirm that continuing education
activities completed during the time a limited license is held may be eligible for the
renewal requirements if certain conditions are met.
I hereby affirm that I will be subject to the grounds for discipline, specifically § 2-
314(10), “Commits any unprofessional act in the practice of … speech-language
pathology” if the minimum continuing education requirements are not completed in the
appropriate time frame.
I hereby affirm that I understand that information regarding the continuing education
requirements to renew a license is posted to the Board’s website.
Signature of Applicant Printed Name of Applicant
Revised October, 2020
11. Affidavit To Be 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 understand that in submitting this application that the accompanying fee is for administrative
purposes and is not refundable. The fee includes licensure fee.
State of County/City 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 required 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.
Please be advised that the disclosure of your Social Security Number (SSN) is mandatory in order to process your
application.
Any license application received at the Maryland Board of Examiners for Audiologists, Hearing Aid Dispensers and
Speech-Language Pathologists without a SSN will not be processed. An application without a SSN is considered
incomplete.
The Board is required by federal and Maryland law to collect this information for the following purposes:
Verification of identity with respect to final adverse actions related to your license or certificate (42 U.S.C.
§ 1320a-7e(b))
Administration of the Child Support Enforcement Program (Md. Family Law Code Ann., § 10-119.3)
Identification by the Maryland Department of Assessments and Taxation of new businesses in Maryland
(Md. Health Occ. Code Ann., § 1-210)
Accordingly, the Board, in order to meet all statutory requirements for the issuance of a license, must have a valid
Social Security Number on file for every applicant/licensee.
Revised October, 2020
*************************************************************************
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 Limited
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 Pathologist
Limited License Clinical Fellowship Year
***Applicant, please check if any of the following apply regarding the submission of this form:
____Change in Employment Site _____Additional Site ___ Change of Supervisor
___
Additional Supervisor
___ Change in Hours
1. Applicant (Please type or print)
A. Name:
Last First Middle/Maiden
B. Address:
Street
City State Zip Code
Phone: Alternate #
C. Academic Status:
College Degree Date Conferred
D. Employment Setting:
1. Facility Name:
2. Address:
Street
City State Zip Code
Phone: Fax
3. Beginning Date of Employment:
Month Day Year
4. Hours per Week spent in Speech-Language Pathology:
5. Are you completing a CFY? Yes No
___
___
II. Supervisor During Limited Licensure Year (Print or Type)
A. Name:
B. Address:
Last First Middle/Maiden
Street
City
C. Place of Employment:
Zip Code
Street
City
Zip Code
Phone: Alternate #:
III. Clinical and Supervisory Responsibility – 80% of total time should be in items 1, 2 and 3
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 MD License in Speech-Language Pathology with License #
( ) Holds ASHA CCC-SLP #
Form AS2
Revised October, 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
Verification of Satisfactory Completion of
Speech-Language Pathologist Clinical Fellowship Year
I hereby declare that, ,
Name of Applicant
an applicant for Maryland licensure in speech-language pathology, was employed as a
professional in that field from to for
(mm/dd/yyyy) (mm/dd/yyyy)
hours per week.
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:
( ) Maryland License in Speech-Language Pathology License, License #
( ) ASHA Certification in Speech-Language Pathology Certificate #
( ) A License in Speech-Language Pathology from State of
whose 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 October, 2020
Current Phone Number
Updated 11/06/2019
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.
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).
Date: ______________________
Name:_____________________
MARYLAND
Department of Health

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Jennir L. Mertes, Board Chair • Candace
G
.
R
o
b
inson, Executive Director
Criminal History Records Check - In Maryland
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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:
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Place of Birth:
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Daytime Phone:
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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
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Mail Response to:
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ame: Do Not Mail This Form To The Board
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ddress: Do Not Mail This Form To The Board
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C
ity, State, Zip code: Do Not Mail This Form To The Board
______________________________________________________________________________
MARYLAND
Department of Health
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 

 
  •  • • 
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Speech-Language Pathologist Limited License Application Checklist (State of Maryland)

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Completed 19 January 2021

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