Fillable TERMINATION OF SUPERVISION (California)

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TERMINATION OF SUPERVISION (California)

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77S-61 (Rev Dec-15)
TERMINATION OF SUPERVISION
FOR SPEECH-LANGUAGE PATHOLOGY ASSISTANT OR RPE
Division 13.4 of Title 16, California Code of Regulations Section 1399.153.9 and 1399.170.18 requires
that at the time of termination of supervision, the supervisor shall submit this original signed form
within 14 days of the termination of supervision for a Speech-Language Pathology Assistant or within
10 days of the termination of supervision for a RPE.
PLEASE CHECK APPLICABLE:
Speech-Language Pathology Assistant
RPE
PART
A – Speech-Language Pathology Assistant or RPE Information (Please Print)
1. FULL LEGAL NAME: LAST FIRST MIDDLE
2. SLPA OR RPE LICENSE NUMBER
SLPA # RPE #
PART B
– Supervisor Information (Please Print)
1. FULL LEGAL NAME: LAST FIRST MIDDLE
2. LICENSE NUMBER OR CREDENTIAL NUMBER
SLP # AU # CREDENTIAL #
I,
Supervisor Name
am terminating the supervision of
SLPA or RPE name
effective as of
I hereby certify under penalty of perjury under the laws of the State of California that all statements made herein
are true in every respect and that misstatements or omissions of material facts may be cause for denial of this
application, or for suspension or revocation of a license.
Signature of Supervisor
Printed Name of Supervisor
Date
Street Address
State
Zip Code
Supervisor’s Telephone Number
DO NOT FAX THIS FORM
THE BOARD REQUIRES ORIGINAL SIGANTURES
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY& HEARING AID DISPENSERS BOARD
1601 RESPONSE ROAD, SUITE 260, SACRAMENTO, CA 95815
PHONE (916) 287-7915 WWW.SPEECHANDHEARING.CA.GOV
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TERMINATION OF SUPERVISION (California)

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Completed 16 June 2021

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