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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  • 34 check-boxes
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Revised February 2022
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: Note: The Law and Regulation Examination is an open book examination. An applicant must
score at least 75 percent to pass the open book law examination. Applicants who submit their
applications online will be sent a link to complete the required law exam electronically. To
complete the examination, use the Law and Regulation links on the Board’s web site.
Refer to the law and regulation reference number included with the questions to get the correct
answer. If you are unable to complete your application online, you may request a paper exam by
emailing Monica Wright. A limited license will not be issued unless the law examination is passed.
Note: C
riminal 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.
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.
Application Processing
Applications are processed continuously in the order received at the Board office. Applications
are only forwarded for Board approval when 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.
Revised February 2022
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.
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.
Revised February 2022
National Examination Score Report:
The Limited Licensee must request a copy of the National Examination, the Praxis Exam, to be
sent to the Board.
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.
Revised February 2022
Revised February 2022
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.
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.
Maryland Department of Health
Board of Examiners for Audiologists, Hearing Aid Dispensers,
Speech-Language Pathologists, and Music Therapist
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 Speech-Language Pathologist-Limited License
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. Phone
#
Alternate #
Email
4. Date of Birth Social Security #
5. What is your first language? English Other___________________
6. Have you previously been licensed in the State of Maryland? If yes,
License # Date Expired
7. 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
_ CHRC Complete Received
CH ( ) MO ( ) Number
Date
Affix current
2x2 passport
size photo
Revised
February 2022
Revised February 2022
8. 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
9. 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
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signature
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10. 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:
11. 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
Revised February 2022
Printed Name of Applicant
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signature
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Revised February 2022
12. 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.
Signed before me
on the ________day of__________________,by_________________________
Name of Applicant
__________________________
Signature of Applicant
____________________________
Signature of Notarial Officer
_________________________
Title of Office
Stamp:
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. § 1320
a-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.
************************************************************************************************************
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 Audiologist, Hearing Aid Dispensers, Speech-Language
Pathologist and Music Therapist without a SSN will not be processed. An application without a SSN is considered incomplete.
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signature
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signature
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Revised February 2022
*************************************************************************
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 Limited
__
Maryland Department of Health
Board of Ex
aminers for Audiologists, Hearing Aid Dispensers,
Speech-Language Pathologists, and Music Therapist
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:
State
Zip Code
Facility Name
Street
City
State
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
Date
Date
Signature of Applicant
Signature of Supervisor
Supervisor:
(
) Holds MD License in Speech-Language Pathology with License #
( ) Holds ASHA CCC-SLP #
Form AS2
Revised February 2022
________
_______
Maryland Department of Health
Board of Examiners for Audiologists, Hearing Aid Dispensers,
Speech-Language Pathologists, and Music Therapist
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
Date
Title
Form AS3
Curre
nt Phone Number
Revised February 2022
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 FB
I 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, AND MUSIC THERAPIST
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, Speech-Language
Pathologists and Music Therapist. 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
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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
& Music Therapist
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, Speech-Language Pathologists and
Music Therapist. 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
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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 Limited License Application Checklist (State of Maryland)

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Completed 2 April 2022

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