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

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

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Revised April, 2020
_
Speech-Language Pathology Assistant – Limited License
Application Checklist
The Board has an open application process. Applications are processed once the application is
complete. An application is considered complete when all of the required materials have been
received by the Board. Applicants are strongly encouraged to make a copy of their application prior
to sending it to the Board. An individual may only begin practicing as a speech-language pathology
assistant after receipt of the limited license.
Individuals who have recently graduated (within the past five years) from a Bachelor’s program in
communications disorders must first obtain a limited license.
I.
All Applicants Must Submit the Following
_ _ $100.00 Non-Refundable Application Fee
(check or money order payable to the Board of SLP)
_ _ A recent 2 inch by 2 inch passport size color photo (attached to first page of application)
_ _ Signed and Notarized Application
_ _ Official Transcript (Proof of graduation from an acceptable program within the last five years)
_ _ Copy of Receipt for Proof of Fingerprinting (Criminal History Records Background Check)
_ _ Law and Regulation Examination completed and returned with Application
Note: Law and Regulation Examination
A minimum score of 75 percent is required to pass the Law Examination. The Exam can
be downloaded from the Board’s web site at https://www.health.maryland.gov/boardsahs/.
Use the Forms Link to download a copy of the Exam. To complete the Examination, refer
to the law and regulations reference numbers included with the question. Use the Law and
Regulation Links on the web site to review the appropriate statute or regulation. If you do
not have access to a computer, call the Board office at 410-764-4725 and request a copy of
the law and regulations. 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.
Revised April, 2020
_
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 CHRC resources page 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 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 at 410-764-4725 to
request an official out-of-state fingerprint card to 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.
II.
Application for a Limited License as a Speech-Language Pathology Assistant
In addition to items in Section I, submit the following documentation:
A.
Education Requirement
Official transcript from college or university verifying one of the following degrees (applicant must
have graduated within 5 years prior to application and transcript must be sent directly to the Board):
_ _ Bachelor’s Degree in Speech-Language Pathology or Communication Disorders
_ _ Associate’s Degree from an approved SLP Assistant Program
_ _ Associate’s Degree or higher in an allied health field from an accredited institution
with minimum course work that includes at least 3 credit hours in normal speech-language
development; speech disorders; anatomy and physiology of speech systems; language
disorders; and phonology (Attach Form SA2 describing required minimum coursework as
stated on transcript)
B.
Clinical Hours Requirement (not required if applicant attended an approved SLP Assistant
program)
Documentation of 25 hours of clinical observation and 75 hours of clinical assistance experience.
Submit one of the following (either the Form SA3 or the Form SA4):
_ Form SA3 Education Institution Verification of Completion of Required Clinical
Hours for applicants that completed the minimum of 25 hours of clinical observation and 75
hours of clinical assistance experience in the educational institution
Revised April, 2020
__
_ _ Form SA4 Alternate Plan for Obtaining Required Clinical Hours signed by applicant
and Supervising Speech-Language Pathologist. This form is required if the applicant did not
obtain any or all of the required clinical hours in the educational program. Please note: all
required clinical observation hours (25) and clinical assistance hours (75) must be completed
within 60 days of the issuance of the limited license and the Form SA5 must be submitted
by the applicant no later than 90 days after issuance of the limited license. Failure to submit
the Form SA5 will result in the limited license becoming null and void.
C.
Delegation Agreement (Form SA6) completed by each Supervising Speech-Language
Pathologist
The supervising speech-language pathologist must meet either of the following two conditions:
a)
be licensed in the State of Maryland; or
b)
if exempt from licensure in Maryland hold the Certificate of Clinical Competency from
ASHA.
To Be Submitted After Initial Limited License Has Been Issued
If a Form SA4 has been submitted to the Board the Form SA5 is due to the Board not sooner than
60 days and not more than 90 days after the limited license is issued. The Form SA5 documents
the completion of the 25 clinical observation hours and 75 clinical assistance hours within 60 days
after the limited license is issued. Limited licensees are encouraged to fax the Form SA5 and mail
the hardcopy immediately to the Board. Limited licensees are encouraged to call the Board to
confirm the Board’s receipt of the Form SA5. If the Board does not receive this form before the
date specified in the licensure letter the limited license is null and void; the Board will send a
notice of a null and void limited license to the individual. If a limited license is null and void the
individual would be required to submit another application for limited licensure.
The Competency Skills Checklist, Form SA7, is due after 9 months of practice under the limited
license but no more than 12 months after the limited license has been issued. If the Limited
Licensee has more than one supervisor the Limited Licensee must have each supervisor complete a
Form SA7. The Limited Licensee is responsible for submitting the Form SA7s to the Board. If the
Limited Licensee does not submit the Competency Skills Checklist the Limited License will be null
and void.
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.
Notice – Application Processing
An application is considered complete when all supporting documents and fees have been received
by the Board. Final processing may take up to 15 business days. The Board will work with the
Revised April, 2020
supervising SLP for issuance of a limited license for the anticipated start date. An individual may
only begin practicing as a speech-language pathology assistant after receipt of the limited
license.
Renewal of Limited License as a Speech-Language Pathology Assistant
If an individual that holds a limited license as a speech-language pathology assistant 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, and/or is unable to complete the items
identified in the Competency Skills Checklist the individual may renew the limited license for an
additional year. The 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 and the Competency Skills Checklist has been submitted to the Board.
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
pathology assistant.
Transfer of Limited License to Full License
An individual holding a limited license as a speech-language pathologist assistant will be
transferred to a full license provided the individual has met all the requirements, the limited
licensee has been supervised for at least 9 months and the supervisor has determined the individual
to be competent for a full license. The Form SA7 must be received by the Board no sooner than
the 9 months of supervised practice ends and no later than 60 days prior to expiration of the limited
license. The limited licensee does not need to fill out another application; however a fee of $100
payable to the Board of Examiners for AHS is required to obtain a full license as a speech-language
pathology assistant.
Revised January 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 Speech-Language Pathology Assistant – Limited License
Date:
Please Read The Application Checklist Before Completing Application Below:
Name:
Last First Middle/Maiden
Date of Birth: Social Security #:
Residence:
Street Apt.
City State Zip Code
Phone #: Alternate #:
E-Mail:
What is your first language? English Other _____________________________________________
Professional Address:
Facility or Company’s Name
Street Suite #
City State Zip Code
Telephone #: Fax: E-Mail:
Anticipated Beginning Date of Employment:
For Office Use Only
Received CK ( ) MO ( ) Number
Affix
Current
Photo
Here
Revised January 2020
Have you ever been convicted of a felony or a misdemeanor involving moral turpitude?
No Yes If “Yes” attach full details.
Has any disciplinary action ever been taken against any license in any other jurisdiction?
No _ _ Yes _ _ If yes, please attach full explanation.
Education
An applicant must have graduated within 5 years prior to application:
A.
School attended:
Address:
Dates Attended: From To:
Degree Granted: Date:
Have School send official transcript verifying education completed directly to the Maryland Board.
B.
Please indicate whether you have one of the following degrees:
1. Bachelor’s Degree in Speech-Language Pathology or Communication Disorders?
_ Yes _ No
2. Associate Degree from an approved SLP Assistant Program? _ Yes _ _No
3. Associate Degree in an allied health field with 15 hours in required minimum course work?
Yes No
Note: If you have an Associate Degree in an allied health field, complete Form SA2 describing required
minimum coursework as stated on transcript. If the title of the course is not self-explanatory, attach
catalog description or syllabus.
C.
Did your educational program include the following required clinical hours as a Speech-Language Pathology
Assistant?
25 hours of clinical observation Yes No
75 hours of clinical assistance Yes No
If you did not attend an approved SLP Assistant Program, attach Form SA3 signed by the Department Chair or
Clinic Director documenting the required clinical hours.
If your educational program did not include the required clinical hours, complete Form SA4 documenting the
Plan that you and the supervising speech-language pathologist have developed to complete the clinical hours
within the first 60 days of limited licensure issuance.
Revised January 2020
Pactice Setting Where Limited Licensee Will Practice
Name of Facility:
Address:
Phone Number: Beginning Date:
Description of Duties:
Supervising Speech-Language Pathologist (s):
Name Title
Name Title
Name Title
Note: A Delegation Agreement, Form SA6, must be submitted for each supervising Speech-Language
Pathologist.
Please review the regulations and sign the following affirmation:
I affirm that I have read the Speech-Language Pathology Assistant regulations, including the sections specifying
activities that are within the scope of practice of SLP Assistants and activities that are not with the scope of
practice of SLP Assistants.
Signature of Applicant Date
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Revised January 2020
Applicant Must Have This Affidavit Completed by a Notary Public
State of
City or 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 if necessary. 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.
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Revised January 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 _ 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-A
Revised January 2020
Form SA2
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
Associate Degree in Allied Health Field
Verification of Minimum Required Coursework
Applicant (please type or print)
Name:
Last First Middle/Maiden
Address:
Street Apt. #
City State Zip Code
Phone #: Alternate #:
Educational Institution
Name of Institution:
Address:
Street:
City State Zip Code
Dates Attended: From To
Associate Degree in granted
(major) (date – mm/dd/yyyy)
Form SA2
Revised January 2020
The Board’s regulations require that an applicant with an Associate’s Degree in an allied health field from an
accredited institution has completed at least 3 credit hours in each of the areas listed below. Please indicate the
name of the course on the transcript that fulfills each requirement and attach an official transcript showing
the Associate Degree. If the title of the course is not self-explanatory, attach catalog description or syllabus.
A minimum of 3 credit hours is required in each of the following areas:
Normal Speech-Language Development
Name of Course
Semester Taken
Additional Courses in this area:
Speech Disorders
Name of Course
Semester Taken
Additional Courses in this area:
Anatomy and Physiology of Speech Systems
Name of Course
Semester Taken
Additional Courses in this area:
Language Disorders
Name of Course
Semester Taken
Additional Courses in this area:
Phonology
Name of Course
Semester Taken
Additional Courses in this area:
Revised January 2020
Form SA3
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
Educational Institution Verification of Completion of Required Clinical Hours
The Board’s regulations require that the speech-language pathology assistant shall demonstrate completion of at
least 25 hours of clinical observation and 75 hours of clinical assistance experience obtained within an
educational institution or in one of the institution’s cooperating programs.
Applicant (Please Type or Print)
Name:
Last First Middle/Maiden
Address:
Street Apt. #
City State Zip Code
Phone: Alternate Phone:
Name of Educational Institution:
Address:
Street
City State Zip Code
Dates Attended (mm/yy): From to
Verification
I verify that completed the following clinical observation hours
Applicant
and clinical assistance hours during the time the applicant was a student.
25 Clinical Observation Hours Completed From to
75 Clinical Assistance Hours Completed From to
Signature Title
Print Name Phone
Revised January 2020
FORM SA4
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
Alternative Plan for Obtaining Required Clinical Hours
This form must be completed if you have not obtained the required 25 clinical observation hours and 75
clinical assistance hours from your educational institution.
Applicant (Please Type or Print)
Name:
Last First Middle/Maiden
Address:
Street Apt. #
City State Zip Code
Phone: E-mail
Supervising Speech-Language Pathologist
Name:
Last First Middle/Maiden
Professional Address:
Facility or Company’s Name
Street Suite #
City State Zip Code
Telephone #
This Plan must be approved by the Board and a Limited License issued before any clinical observation or
clinical assisting experience is obtained. Experienced gained in violation of the laws and regulations will not be
accepted as having met the licensure requirements.
The Alternative Plan must ensure that the applicant will obtain the required 25 clinical observation hours and
75 clinical assisting hours within 60 days of the applicant’s receipt of a limited License. The plan shall be
designed and signed by the supervising speech-language pathologist. If the Board does not receive proof of
successful completion of the hours by the end of 90 days, the assistant’s Limited License is void and the
assistant will need to reapply.
The 75 hours of clinical assistance shall include 100% direct supervision by the supervising speech-language
pathologist of the speech-language pathologist assistant during any client contact hours. The first month of
clinical hours must start after the Board approves the Form SA4.
Revised January 2020
FORM SA4
Pursuant to COMAR 10.41.11.08(B) “a licensed full-time (35 hours or more a week) speech-language
pathologist may not supervise more than the equivalent of two full-time (35 hours or more a week) speech-
language pathology assistants.” Pursuant to COMAR 10.41.11.08(C) “a licensed part-time (35 hours or more a
week) speech-language pathologist may not supervise more than the equivalent of one full-time (35 hours or
more a week) speech-language pathology assistant.” The Board will not issue a full SLP-A license or limited
SLP-A license to an applicant until it is satisfied that the supervisor noted on the Form SA4 is in compliance
with the foregoing regulations.
Alternative Plan for Clinical Hours
Week
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Observation Hours
Assistance Hours
1
2
3
4
5
6
7
8
9
10
11
12
Grand Total Hours:
Signature of Applicant _ Date
Signature of Supervisor Date
Supervisor: (select one of the following)
( ) Holds MD License in Speech-Language Pathology
( ) Holds ASHA CCC-SLP
( ) Holds Licensure in SLP in State of
Revised January 2020
FORM SA5
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 Completion of Required Clinical Hours
The limited licensee must submit the Form SA5 to the Board when the assistant has completed the required
25 clinical observation hours and 75 clinical assistance hours. The required hours must be completed within
the first 60 days of issuance of Limited Licensure. This form must be submitted to the Board by the end of 90
days of issuance of a Limited License as specified in the letter received with the limited license. If this form is
not submitted by the date specified in the letter enclosed with the limited licensee the limited license becomes
null and void per COMAR 10.41.11.03(B)(2)(e).
Applicant (Please Type or Print)
Name:
Last First Middle/Maiden
Address:
Street Apt. #
City State Zip Code
Phone: E-Mail:
Supervising Speech-Language Pathologist
Name:
Last First Middle/Maiden
Address:
Facility or Company Name
Street Suite #
City State Zip Code
Phone #: E-Mail:
Revised January 2020
FORM SA5
I verify that, , a Speech-Language Pathology Assistant
Applicant under my supervision has completed 25 hours of clinical observation and 75 hours of clinical
assisting experience as indicated below:
Week
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Observation Hours
Assistance Hours
1
2
3
4
5
6
7
8
9
10
11
12
Grand Total Hours:
Signature of Supervisor: Date:
Supervisor: (check one of the following)
( ) Holds MD License in Speech-Language Pathology, License #
( ) Holds ASHA CCC-SLP, Certificate #
( ) Holds Licensure in SLP in State of , License #
If the Board does not receive proof of successful completion of the clinical hours by the end of 90 days,
the Speech-Language Pathology Assistant’s Limited License will be null and void. The Speech-Language
Pathology Assistant may practice only after reapplying for a new limited license.
Revised January 2020
FORM SA6
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
Delegation Agreement
A Speech-Language Pathology Assistant or an applicant for licensure as a Speech-Language Pathology
Assistant must file a Delegation Agreement with the Board. A separate agreement must be filed for each
supervising Speech-Language Pathologist under whom the SLP Assistant will be working. Each Delegation
Agreement must be re-filed at the time of license renewal. Additionally, if there is a change of supervision
(adding or removing), a new Delegation Agreement must be filed immediately.
Speech-Language Pathology Assistant Information:
Applicant’s Name:
Mailing Address:
Telephone: Alternate:
If currently licensed as an assistant, Maryland SLP Assistant License Number:
Supervising Speech-Language Pathologist
Name:
Address:
Telephone: Alternate:
Maryland SLP License Number: and/or ASHA Number:
Facility Information (where the SLP Assistant Limited Licensee will be practicing)
Facility Name:
Facility Address:
Contact Person: Phone:
Revised January 2020
FORM SA6
Will the supervising Speech-Language Pathologist be responsible for the practice of the
SLP Assistant at additional facilities? _ Yes _ No
If yes, please indicate the additional facilities and their addresses here:
Delegation Agreement
The Speech-Language Pathology Assistant named in this Delegation Agreement is authorized to assist the
supervising Speech-Language Pathologist named in this agreement in the implementation of speech-language
pathology treatment goals and related activities as outlined in the SLP Assistant Regulations (COMAR
10.41.11) under the direction of the supervising SLP at the above named facility(ies).
The Supervising Speech-Language Pathologist agrees to supervise the SLP Assistant according to the standards
outlined in the COMAR regulations; the Speech-Language Pathologist may not supervise more than the
equivalent of two (2) full-time students (SLP assistants and/or SLP clinical fellows and/or clinical interns) per
day in off-site placements.
The SLP Assistant agrees to perform only those activities authorized in the COMAR
regulations.
The SLP Assistant agrees to notify the Board if this Delegation Agreement is no longer valid.
Signature of SLP Assistant Date
Signature of Supervising SLP Date
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Revised January 2020
FORM SA7
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
Competency Skills Checklist
At the beginning of the Assistant’s Limited Licensure:
The Supervising Speech-Language Pathologist and the Speech-Language Pathology Assistant should review the
Competency Skills Checklist at the beginning of the period of limited licensure and periodically thereafter.
Discussion of the skills required and review of the Assistant’s progress towards acquiring these skills can prove
useful throughout the limited licensure period. Using the Checklist as a learning tool will provide clear goals
for the Assistant and lead to the successful completion of the Checklist at the end of the nine months of
supervised practice.
After 9 months of supervised practice:
The Competency Skills Checklist is to be completed by the supervising Speech-Language Pathologist after the
Speech-Language Pathology Assistant has completed a minimum of nine (9) months of supervised practice
under a limited license. Completion of the Checklist verifies that the Assistant has acquired the skills and
knowledge needed to receive a full license as a Speech-Language Pathology Assistant.
The Speech-Language Pathology Assistant shall submit the completed Competency Skills Checklist to the
Board at least 60 days before the limited license expiration date.
Revised January 2020
FORM SA7
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
Competency Skills Checklist
Speech-Language Pathology Assistant:
Supervising Speech-Language Pathologist:
Directions: The supervising speech-language pathologist marks Yes or No to indicate that the assistant is
competent and meets the criteria. If the supervisor marks “not applicable” (N/A), the supervisor must include
an explanation.
I.
Interpersonal Skills
Standard: The speech-language pathology assistant actively demonstrates cooperation, adaptability, and
effective communication.
1. Criteria: Deals effectively with the attitudes and behaviors of the patients/clients
Yes No
2. Criteria: Communicates and interacts effectively with supervisor
Yes No
II.
Personal Qualities:
Standard: The speech-language pathology assistant demonstrates professional behavior and confidentiality.
1. Criteria: Demonstrates behaviors of a dependable team member which may include:
Yes No
c. Completes assigned tasks within designated treatment session
b. Submits documentation on time
a. Arrives punctually to appointments with prepared assignments
d. Other:
c. Actively participates in interactions with supervisor
b. Requests assistance from supervisor appropriately
a. Accepts and responds appropriately to constructive criticism
f. Other:
e. Refers patient/client/caregivers/other professionals to the supervising speech-language
pathologist when appropriate
d. Demonstrates insight into patient/client and caregivers attitudes and behaviors
c. Addresses/considers patient/client and significant others cultural needs and values
b. Communicates effectively and with sensitivity the needs of the patient/client, family and
caregivers
a. Maintains appropriate patient/client relationships
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Revised January 2020
2. Criteria: Demonstrates appropriate conduct in the work environment, which may include:
Yes No
III.
Technical-Assistant Skills
Standard: The speech-language pathology assistant assists the therapist in providing adequate treatment.
1. Criteria: Maintains a facilitating environment for all tasks
Yes No
a. Adjusts environment to facilitate learning (i.e. lights, noise, etc)
b. Organizes treatment space appropriately
c. Other:
2. Criteria: Selects prepares and presents materials effectively
Yes No
3. Criteria: Complies with documentation standards
Yes No
4. Criteria: Provides assistance to the supervising speech-language pathologist
Yes No
IV.
Screenings
Standard: The speech-language pathology assistant will provide appropriate screening procedures.
1. Criteria: Administers screening tools appropriately as directed by the supervisor for communication and/or
swallowing disorders which may include
Yes No
a. Differentiates correct vs. incorrect responses
b. Completes screening protocol form accurately
a. Assists the supervisor as directed during assessments by the speech-language
pathologist
b. Assist with informal documentation
c. Schedules activities appropriately
d. Participates with the supervisor in research projects
e. Participates in in-services training
f. Participates in public relations programs
g. Performs checks and maintenance of equipment
d. Prepares and maintains client records, charts, graphs, objective data as directed by the
supervisor
c. Signs documents and assures co-signature when required
b. Documents client progress and performance to supervisor
a. Documents treatment plans and protocols accurately, completely and concisely for the
supervising speech-language pathologist
c. Recognizes own professional limitations and performs within the boundaries of training
and job responsibilities
b. Maintains professional appearance for work environment
a. Maintains confidentiality of client information at all times
a. Selects and prepares appropriate treatment materials
b. Selects treatment materials based on clients age, needs, culture and motivation
Revised January 2020
2. Criteria: Manages screening
Yes No
3. Criteria: Communicates results to supervising speech-language pathologist
No
V.
Treatment
Standard: The speech-language pathology assistant provides appropriate treatment
resulting in optimal client improvement.
1. Criteria: Performs treatment tasks as outlined by the supervisor
Yes No
a. Accurately and efficiently follows treatment plans developed by the speech-language
pathologist
b. Incorporates feedback from speech-language pathologist for modifying own behavior
with the client, caregivers and other professional staff
2. Criteria: Manages client behavior and provides appropriate treatment
Yes No
3. Criteria: Demonstrates knowledge of treatment objectives and plan
Yes No
I verify that, ,
Speech-Language Pathology Assistant has completed a minimum of nine (9) months of supervised practice as a
Speech-Language Pathology Assistant under my supervision and has obtained the knowledge and skills needed
to obtain a full license as a Speech-Language Assistant.
Supervising Speech-Language Pathologist Date
a. Demonstrates understanding of client disorder and needs
b. Identifies correct vs. incorrect responses
c. Identifies client behaviors which demonstrate an improvement in function
d. Accurately reports completion of tasks
a. Maintains on-task behavior
b. Provides appropriate feedback to the client as to the accuracy of the response
c. Uses feedback and reinforcement that are consistent, discriminating and meaningful
d. Gives direction and instructions that are age, education and culturally appropriate
e. Implements treatment objectives/goals in specified sequence
f. Applies behavior modification and other reinforcement behavior appropriately as
designated by the speech language pathologist
a. Seeks guidance when appropriate
b. Provides descriptive behavioral observations that contribute to results
c. Organizes screening materials
b. Schedules screenings
a. Reports any difficulties encountered with screening procedures
Yes
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Revised January 2020
FORM SA8
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
Affidavit To Be Completed By Licensure Board
This portion of the form is to be completed by the Speech-Language Pathology Assistant:
Please verify _ licensure certification or registration as a Speech-Language
Pathology Assistant in your State for:
First Name Middle Last Name
Date of Birth: Social Security Number:
License/Certificate/Registration Number:
This portion of the affidavit is to be completed by the Board:
License/Certificate /Registration Number: Date Issued:
Is License/Certificate/Registration in good standing?
Expiration Date:
Please provide basis for qualifying for license/certificate/registration as a Speech-Language Pathology Assistant
in your state that this person met (e.g. educational requirements, practice requirements, examination, etc.)
Please attach law and regulations governing Speech-Language Pathology Assistants for your state.
Has License/Certificate/Registration ever been suspended or revoked? No Yes __
If yes, please explain why or attach additional explanation.
Revised January 2020
Has License/Certificate/Registration been reinstated?
Has disciplinary action ever been taken against this person? If yes, please explain why or attach
additional explanation.
Is there any derogatory information on file concerning this person? No _ Yes _ _
If yes, please explain or attach additional explanation.
Signature Date
Title
State Board of
State of
State Seal Here
FORM SA8
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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.
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).
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 - 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.
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
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 Pathology Assistant Limited License Application Checklist (State of Maryland)

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