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Application Checklist for Speech-Language Pathology
or Audiology Aide
Registration of an Aide
If you need assistance, please email the Board at
speechandhearing@dca.ca.gov
1. Application
• Please remember to submit a 2x2 passport quality photograph.
• If you have multiple supervisors, a separate application with the $10 fee
must be submitted for each supervisor.
2. Fees
• Please submit a check or money order to the Board in amount of $10, made
payable to SLPAHADB.
3. Fingerprints
• California applicants are required to use Live Scan for fingerprinting; please submit
a copy of the completed form to the Board. Fees are paid directly to the Live Scan
operator.
• Out-of-State applicants are required to submit two fingerprint cards (FD-258) and a
check or money order to the Board for $49.00(DOJ and FBI processing fee).
• One (1) check or money order in the amount of $59 ($10 licensing fee and
$49 fingerprint card processing fees) may be submitted. Please make check
or money order payable to SLPAHADB.
BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY & HEARING AID DISPENSERS BOARD
2005 Evergreen Street, Suite 2100, Sacramento, CA 95815
P (916) 263-2666 | www.speechandhearing.ca.gov
REGISTRATION OF SPEECH-LANGUAGE PATHOLOGY OR AUDIOLOGY AIDE
$10.00
INSTRUCTIONS: Do not print this application double-sided. You must complete Part A and your
supervisor must complete Part B. Any corrections to this form must be crossed out and initialed.
APPLICATION TYPE: (Check one)
Audiology Aide
Speech-Language Pathology Aide
PART A – Personal Information
1. FULL LEGAL NAME: LAST FIRST MIDDLE
2. OTHER NAMES YOU HAVE USED (INCLUDING MAIDEN):
3. STREET ADDRESS CITY STATE ZIP
BUSINESS TELEPHONE:
NUMBER (ITIN):
6. DATE OF BIRTH: (MM/DD/YYYY)
7. EMAIL ADDRESS:
8. ARE YOU, OR A SPOUSE, OR A DOMESTIC PARTNER OF ACTIVE DUTY MILITARY PERSONNEL? Yes
No
IF YES, YOU MAY QUALIFY FOR EXPEDITED APPLICATION PROCESSING. AN APPLICANT FOR EXPEDITED APPLICATION
PROCESSING MUST MEET THE FOLLOWING REQUIREMENTS: 1) PROVIDE EVIDENCE THAT THE APPLICANT IS MARRIED TO, OR
IN A DOMESTIC PARTNERSHIP OR OTHER LEGAL UNION WITH, AN ACTIVE DUTY MEMBER OF THE ARMED FORCES OF THE
UNITED STATES WHO IS ASSIGNED TO A DUTY STATION IN CALIFORNIA UNDER OFFICIAL ACTIVE DUTY ORDERS AND; 2) HOLD A
CURRENT LICENSE IN ANOTHER STATE, DISTRICT, OR TERRITORY OF THE UNITED STATES IN HEARING AID DISPENSING.
9. ARE YOU AN HONORABLY DISCHARGED VETERAN OF THE ARMED FORCES? Yes
No
IF YES, YOU MAY QUALIFY FOR EXPEDITED APPLICATION PROCESSING. AN APPLICANT FOR EXPEDITED APPLICATION
PROCESSING MUST MEET THE FOLLOWING REQUIREMENT: 1) SUPPLY SATISFACTORY EVIDENCE TO THE BOARD THAT THE
APPLICANT HAS SERVED AS AN ACTIVE DUTY MEMBER OF THE ARMED FORCES OF THE UNITED STATES AND WAS HONORABLY
DISCHARGED.
10. BUSINESS AND PROFESSIONS CODE SECTION 135.4 PROVIDES THAT THE BOARD MUST EXPEDITE, AND MAY ASSIST, THE
INITIAL LICENSURE PROCESS FOR CERTAIN APPLICANTS DESCRIBED BELOW.
DO ANY OF THE FOLLOWING STATEMENTS APPLY TO YOU? YES NO
• YOU WERE ADMITTED TO THE UNITED STATES AS A REFUGEE PURSUANT TO SECTION 1157 OF TITLE 8 OF THE UNITED STATES
CODE;
• YOU WERE GRANTED ASYLUM BY THE SECRETARY OF HOMELAND SECURITY OR THE UNITED STATES ATTORNEY GENERAL
PURSUANT TO SECTION 1158 OF TITLE 8 OF THE UNITED STATES CODE; OR,
• YOU HAVE A SPECIAL IMMIGRANT VISA AND WERE GRANTED A STATUS PURSUANT TO SECTION 1244 OF PUBLIC LAW 110-181,
PUBLIC LAW 109-163, OR SECTION 602(B) OF TITLE VI OF DIVISION F OF PUBLIC LAW 111-8, RELATING TO IRAQI AND AFGHAN
TRANSLATORS/INTERPRETERS OR THOSE WHO WORKED FOR OR ON BEHALF OF THE UNITED STATES GOVERNMENT.
IF YOU SELECTED YES, YOU MUST ATTACH EVIDENCE OF YOUR STATUS AS A REFUGEE, ASYLEE, OR SPECIAL IMMIGRANT VISA
HOLDER. FAILURE TO DO SO MAY RESULT IN APPLICATION REVIEW DELAYS.
SLP/AUD Aide 11.2020 Page 1 of 4
PART A – Continued
A YES answer to any of the questions below (10 through 13), requires you to
complete and submit the Discipline Reporting Form.
YES
NO
11. Have you ever been the subject of a disciplinary action or have any pending disciplinary action
taken or charges filed against any speech-language pathology, audiology, hearing aid
dispensing, or other healing arts license? Include any disciplinary action taken by any other
state or Federal Government entity?
This includes,
but is not limited to suspension, revocation, probation, confidential discipline,
consent order, letter of reprimand or warning, or any other restriction of actions taken against a
license.
12. Have you had any pending investigations by any State or Federal agencies against you?
13. Have you been denied a license to practice speech-language pathology, audiology, hearing
aid dispensing, or other healing arts, in any state or country?
14. Have you voluntarily surrendered a license to practice speech-language pathology, audiology,
hearing aid dispensing, or other healing arts in another state or country?
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.
________________________________________________
Applicant’s Signature
__________
Date
INFORMATION COLLECTION AND ACCESS
The Speech-Language Pathology & Audiology & Hearing Aid Dispensers Board’s Executive Officer is the person who is responsible for
information maintenance. Section 2532 of the Business and Professions Code is the authority, which authorizes the maintenance of the
information. All information is mandatory. Failure to provide any mandatory information will result in the application being rejected as
incomplete. The information provided will be used to determine qualification for licensure. Each individual has the right to review his or her file
maintained by the agency subject to the provisions of the California Public Records Act.
Notice: Effective July 1, 2012, the State Board of Equalization and the Franchise Tax Board may share taxpayer information with
the Board. You are obligated to pay your state tax obligation and your license may be suspended if your tax obligation is not paid.
SLP/AUD Aide 11.2020 Page 2 of 4
PART B – To be completed by the Supervisor
Refer to Title 16, California Code of Regulations, Section 1399.154.2 for supervisor’s responsibilities.
15. FULL LEGAL NAME OF SUPERVISOR: LAST FIRST MIDDLE
STREET ADDRESS:
CITY, STATE, ZIP CODE:
16. BUSINESS TELEPHONE: LICENSE NUMBER:
17. EMAIL ADDRESS:
18. List all duties the aide will perform in assisting the supervisor/licensee in the practice of speech-language pathology or audiology. For each
duty listed, describe the method of supervision. Please be very specific.
19. For each duty listed in section A above, describe in detail the supervisor’s training methods, the necessary minimum competency level of
the aide, the manner in which the aide’s competency will be assessed, the person(s) responsible for the training, a summary of past education,
training, and experience the aide may already have acquired, the length of the training program, and assessment of the aides, competency level.
Include a copy of any training manuals to be used.
I, the aide applicant, have discussed the plan for supervision with this supervisor and agree to its implementation. I
further certify under penalty of perjury under the laws of the state of California that all statements made in the
application are true and correct. Any misrepresentation may be caused for denial of my license.
APPLICANT’S SIGNATURE: ___________________________________________________ DATE SIGNED: __________
I, the aide supervisor, have discussed the plan for supervision with the aide applicant and hereby accept
professional and ethical responsibility for his or her performance. I further certify under penalty of perjury under the
laws of the state of California that all statements made in part B are true and correct.
SUPERVISOR’S SIGNATURE: __________________________________________________ DATE SIGNED: __________
SLP/AUD Aide 11.2020 Page 3 of 4
SPEECH-LANGUAGE PATHOLOGY OR AUDIOLOGY AIDE REGISTRATION
Duties and Responsibilities of Aide
Aide applicants and applicant’s supervisor must read and sign this form under the penalty of perjury.
Please submit with the completed Aide application.
1) I have read and understand the laws and regulations, included with my application, pertaining to the
responsibilities of a speech-language pathology or audiology aide registration holder.
2) My supervisor shall maintain a current license issued by the Board, during the time of my supervision. If my
supervisor’s license expires during the course of professional experience, I will immediately notify the board. A
supervisor’s license can be verified at any time at the Board’s website.
3) I understand that I am required to have 100% direct supervision when assisting with patients.
4) I understand that any experience obtained as an aide shall not be creditable toward the supervised clinical
experience required as a speech-language pathologist or audiologist.
APPLICANT SIGNATURE
PRINTED FULL LEGAL NAME OF APPLICANT
DATE
Duties and Responsibilities of Supervisor
1) I possess the following qualification to supervise an Aide applicant: a California Speech-Language Pathologist or
Audiologist license; or (if employed by a public school) a clear, valid, teaching credential authorizing service in
language, speech, and hearing issued by the Commission on Teacher Credentialing.
2) I agree to ensure that either my California licensee or my teaching credential is renewed in a timely manner.
3) I agree to provide 100% direct supervision to the aide when assisting with patients.
4) I will not supervise more than three aides at any one time pursuant to California Code of Regulations Section
1399.154.3.
5) I will immediately notify the aide of any disciplinary action, including revocation, suspension (even if stayed),
probation terms, inactive licensure, or lapse in licensure that affects my ability or right to supervise.
6) I have read and understand the laws and regulations pertaining to the supervision of the aide.
7) I shall establish and complete a training program for a speech-language pathology or audiology aide in
accordance with Section 1399.154.4 which is unique to the duties of the aide and the setting in which he or she
will be assisting the supervisor.
SIGNATURE OF SUPERVISOR
PRINT FULL LEGAL NAME OF SUPERVISOR
LICENSE NUMBER OR CREDENTIAL NUMBER
Date
(Please attach a copy of the front and back of your credential)
SLP/AUD Aide 11.2020 Page 4 of 4
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Completed 13 April 2021

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