Application Checklist for Speech-Language Pathology Assistant

Transcription

1 Application Checklist for Speech-Language Pathology Assistant 1. Application 2. Registration Fees Check or Money Order to Board for $ Fingerprints If a California resident, must do Livescan; send a copy of your form to the Board. Fees paid directly to Livescan Operator. If out-of-state, send two fingerprint cards (FD 258) and a check or money order to Board for $49 to cover DOJ and FBI. 4. Transcripts Sent directly from the universities. 5. Copy of Diploma If you have completed the coursework equivalent to a Bachelor s degree in speech-language pathology, we require a letter sent directly from your university to our Board verifying completion of the required coursework. 6. Verification Form submit one of the three forms Fieldwork Experience Verification Form (SLPA Program). Fieldwork Experience Verification Form -Undergraduate Clinical Experience (Bachelor s Program). Employment Work Experience Verification (Bachelor s Degree Holders). If you are a current license holder in another state and the spouse or domestic partner of an active duty member of the U.S. Armed Forces, your license application may be expedited. Must submit proof of your marriage certificate or legal union. Must submit copy of active duty military orders for assignment to a California duty station. Must submit proof of your current license that you hold in another state in the profession for which you are applying. If you meet these qualifications, please the Board for further instructions: speechandhearing@dca.ca.gov

2 SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY & HEARING AID DISPENSERS BOARD 2005 EVERGREEN STREET, SUITE 2100, SACRAMENTO, CA PHONE (916) FAX (916) APPLICATION FOR SPEECH-LANGUAGE PATHOLOGY ASSISTANT OFFICE USE ONLY RECEIPT #: ATS #: AMOUNT PAID: INSTRUCTIONS: ALL SECTIONS OF THIS APPLICATION MUST BE COMPLETED. ANY CORRECTIONS TO THIS FORM MUST BE STRICKEN AND INITIALED. DO NOT USE WHITE OUT ON THIS APPLICATION. MAIL COMPLETED APPLICATION, ALL SUPPORTING DOCUMENTS, AND $50.00 (NON-REFUNDABLE) FEE PAYABLE TO: SLPAHADB. DATE CASHIERED: 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 THE STATE TAX OBLIGATION IS NOT PAID. PLEASE PRINT (IN BLUE INK) OR TYPE. 1. FULL NAME: LAST FIRST MIDDLE 2. OTHER NAMES YOU HAVE USED: 3. *ADDRESS OF RECORD: STREET CITY STATE ZIP CODE ADDRESS: 4. RESIDENCE TELEPHONE: BUSINESS TELEPHONE: 5. SOCIAL SECURITY NUMBER: DATE OF BIRTH: 6. BASIS FOR FILING: ASSOCIATE OF ARTS OR SCIENCES DEGREE BACHELOR S DEGREE BACHELOR S DEGREE EQUIVALENCY 7. LIST NAME AND LOCATION OF ALL SATISFACTORILY COMPLETED UNDERGRADUATE EDUCATION. YOU MUST HAVE OFFICIAL TRANSCRIPTS DIRECT TO THE BOARD FROM EACH INSTITUTION. INSTITUTION NAME CITY/STATE MAJOR FIELD OF STUDY DEGREE RECEIVED AND DATE 8. PLEASE CHECK THE APPROPRIATE QUALIFYING EXPERIENCE: AA/AS FIELDWORK EXPERIENCE UNDERGRADUATE FIELDWORK EXPERIENCE EMPLOYMENT WORK EXPERIENCE (*) Applicable work experience as defined in the above code section means the execution of duties or tasks of a speech-language pathology assistant as defined in Business and Professions Code Section (b)(4), for a minimum of nine months of full-time (30 hours a week or more) work experience. Work Experience completed while working in the capacity of a registered speech-language pathology aide under direct supervision does not qualify under this provision. *YOUR ADDRESS OF RECORD IS PUBLIC INFORMATION AND WILL BE PLACED ON THE INTERNET.

3 9. HAVE YOU EVER BEEN LICENSED OR REGISTERED AS A SPEECH-LANGUAGE PATHOLOGY ASSISTANT BY ANY STATE, THE FEDERAL GOVERNMENT OR OTHER TERRITORY OF THE UNITED STATES? (IF YES, LIST ALL STATES OR COUNTRIES WHERE YOU WERE ISSUED A LICENSE OR REGISTRATION.) YES NO STATE: YOU MUST PROVIDE A LETTER OF GOOD STANDING FROM EACH STATE LISTED. 10. HAVE YOU BEEN THE SUBJECT OF ANY DISCIPLINARY ACTION REGARDING ANY SPEECH-LANGUAGE PATHOLOGY ASSISTANT REGISTRATION/LICENSE OR HEALING ARTS LICENSE WHICH YOU NOW HOLD OR HAVE PREVIOUSLY HELD IN ANY STATE OR COUNTRY? YES NO (IF YES, COMPLETE THE CONVICTION/LICENSE DISCIPLINARY ACTION FORM) 11. ARE THERE ANY PENDING INVESTIGATIONS BY ANY STATE OR FEDERAL AGENCIES AGAINST YOU? YES NO (IF YES, COMPLETE THE CONVICTION/LICENSE DISCIPLINARY ACTION FORM) 12. HAVE YOU EVER BEEN DENIED A SPEECH-LANGUAGE PATHOLOGY ASSISTANT LICENSE OR REGISTRATION OR ANY OTHER HEALING ARTS LICENSE OR REGISTRATION, BY ANY STATE, THE FEDERAL GOVERNMENT, OR OTHER TERRITORY OF THE UNITED STATES? YES NO (IF YES, COMPLETE THE CONVICTION/LICENSE DISCIPLINARY ACTION FORM) 13. HAVE YOU EVER VOLUNTARILY SURRENDERED A LICENSE OR REGISTRATION TO PRACTICE IN ANY STATE, FEDERAL AGENCY, OR OTHER TERRITORY OF THE UNITED STATES? YES NO (IF YES, COMPLETE THE CONVICTION/LICENSE DISCIPLINARY ACTION FORM) 14. HAVE YOU EVER BEEN CONVICTED OF, OR PLED NOLO CONTENDERE TO ANY OFFENSE, MISDEMEANOR OR FELONY OF ANY STATE, THE UNITED STATES, OR A FOREIGN COUNTRY? (EXCEPT VIOLATIONS OF TRAFFIC LAWS RESULTING IN FINES OF $300 OR LESS) YES NO (IF YES, COMPLETE THE CONVICTION/LICENSE DISCIPLINARY ACTION FORM) YOU ARE REQUIRED TO LIST ANY CONVICTION THAT HAS BEEN SET ASIDE AND/OR DISMISSED UNDER PENAL CODE SECTION YOU MUST REPORT TO THE BOARD THE RESULT OF ANY ACTIONS WHICH HAVE BEEN FILED OR WERE PENDING AGAINST ANY SPEECH- LANGUAGE PATHOLOGY ASSISTANT LICENSE OR REGISTRATION YOU HOLD AT THE FILING OF THIS APPLICATION. FAILURE TO REPORT THIS INFORMATION MAY RESULT IN THE DENIAL OF YOUR APPLICATION OR SUBJECT YOUR LICENSE TO DISCIPLINE PURSUANT TO SECTION 480 (C) OF THE BUSINESS AND PROFESSIONS CODE. ATTACH 2 X 2 OR 3 X 3 PASSPORT QUALITY PHOTOGRAPH HERE. YOU MUST PRINT YOUR FULL NAME ON THE BACK OF THE PHOTOGRAPH. THE PHOTOGRAPH MUST HAVE BEEN TAKEN WITHIN THE 60 DAYS OF THE FILING DATE OF THIS APPLICATION. PHOTOS PRINTED ON WHITE PAPER ARE NOT ACCEPTABLE. 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. I FULLY UNDERSTAND THAT I MAY NOT PRACTICE AS A SPEECH-LANGUAGE PATHOLOGY ASSISTANT IN THE STATE OF CALIFORNIA WITHOUT WRITTEN NOTIFICATION FROM THE CALIFORNIA SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY & HEARING AID DISPENSERS BOARD THAT I MAY DO SO. 77A-60 (REV Jan-12) DATE: SIGNATURE: (SIGNATURE MUST BE IN BLUE INK)

4 SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY & HEARING AID DISPENSERS BOARD 2005 EVERGREEN STREET, SUITE 2100, SACRAMENTO, CA PHONE (916) FAX (916) FIELDWORK EXPERIENCE VERIFICATION FORM INSTRUCTIONS: COMPLETE ALL SECTIONS OF THE FORM AND SEND TO COLLEGE OR UNIVERSITY FOR VERIFICATION AND SIGNATURE BY CURRENT TRAINING PROGRAM DIRECTOR/COORDINATOR. PLEASE PRINT OR TYPES. ALL SIGNATURES MUST BE IN BLUE INK. APPLICANT S NAME: SOCIAL SECURITY NUMBER: UNIVERSITY OR COLLEGE: Supervisor s Full Name & License Number Location Where Experience Was Obtained Dates of Experience From (Mo/Yr) To Mo/Yr) Total Hours Earned TOTAL: I certify that all fieldwork experiences listed on this form were completed according to the State of California requirements. I further certify under penalty of perjury under the laws of the State of California that all statements made herein are true in every respect. Signature of Current Training Program Director/Coordinator Date Applicant s Signature 77A-61 (Rev Sep-11)

5 SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY & HEARING AID DISPENSERS BOARD 2005 EVERGREEN STREET, SUITE 2100, SACRAMENTO, CA PHONE (916) FAX (916) FIELDWORK EXPERIENCE VERIFICATION FORM UNDERGRADUATE CLINICAL EXPERIENCE INSTRUCTIONS: COMPLETE ALL SECTIONS OF THE FORM AND SEND TO COLLEGE OR UNIVERSITY FOR VERIFICATION AND SIGNATURE BY CURRENT TRAINING PROGRAM DIRECTOR/COORDINATOR. PLEASE PRINT OR TYPES. ALL SIGNATURES MUST BE IN BLUE INK. APPLICANT S NAME: SOCIAL SECURITY NUMBER: UNIVERSITY OR COLLEGE: Location Where Experience Was Obtained Dates of Experience From (Mo/Yr) To Mo/Yr) Total Hours Earned TOTAL: I certify that all fieldwork experiences listed on this form were completed according to the State of California requirements. I further certify under penalty of perjury under the laws of the State of California that all statements made herein are true in every respect. Signature of Applicant (Blue Ink) Date Signature of Current Training Program Director (Blue Ink) Date (REV Sep-11)

6 BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY GOVERNOR EDMUND G. BROWN JR. SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY& HEARING AID DISPENSERS BOARD 2005 EVERGREEN STREET, SUITE 2100, SACRAMENTO, CA PHONE (916) FAX (916) EMPLOYMENT WORK EXPERIENCE VERIFICATION FORM FOR BACHELOR S DEGREE HOLDERS INSTRUCTIONS: COMPLETE ALL SECTIONS OF THE FORM AND SEND TO EMPLOYER FOR VERIFICATION OF INFORMATION. ALL SIGNATURES MUST BE IN BLUE INK. DO NOT USE WHITE OUT ON THIS FORM. YOU MUST COMPLETE A SEPARATE FORM FOR EACH EMPLOYER. WORK EXPERIENCE COMPLETED WHILE WORKING IN THE CAPACITY OF A REGISTERED SPEECH-LANGUAGE PATHOLOGY AIDE UNDER DIRECT SUPERVISION DOES NOT QUALIFY UNDER THIS PROVISION. APPLICANT S NAME: ADDRESS OF RECORD: SOCIAL SECURITY NUMBER: *EMPLOYER S NAME AND ADDRESS: *IF THIS IS A NON-PUBLIC AGENCY OR NON-PUBLIC SCHOOL YOU MUST ATTACH VERIFICATION. POSITION TITLE: DATES OF EMPLOYMENT: FROM (MM/DD/YYYY): TO (MM/DD/YYYY): TOTAL HOURS PER WEEK WORKED THE FOLLOWING INFORMATION MUST BE COMPLETED BY THE RESPONSIBLE SUPERVISOR: IMMEDIATE SUPERVISION - IN VIEW AND WITH SUPERVISING SPEECH-LANGUAGE PATHOLOGIST PHYSICALLY PRESENT. DIRECT SUPERVISION - ONSITE/AVAILABLE FOR IN-PERSON CONSULTATION AND OVERSIGHT. INDIRECT SUPERVISION - AVAILABLE FOR CONSULTATION VIA TELEPHONE CONTACT OR OTHER ELECTRONIC MEANS. LIST ALL DUTIES/TASKS PERFORMED BY THE APPLICANT BE VERY SPECIFIC TYPE OF SUPERVISION PROVIDED FOR EACH DUTY/TASK PERFORMED, E.G. IMMEDIATE, DIRECT,OR INDIRECT

7 APPLICANT NAME SOCIAL SECURITY NUMBER LIST ALL DUTIES/TASKS PERFORMED BY THE APPLICANT BE VERY SPECIFIC TYPE OF SUPERVISION PROVIDED FOR EACH DUTY/TASK PERFORMED, E.G. IMMEDIATE, DIRECT, OR INDIRECT I CERTIFY THAT ALL WORK EXPERIENCE LISTED ON THIS FORM WAS COMPLETED ACCORDING TO THE STATE OF CALIFORNIA REQUIREMENTS. I FURTHER CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT ALL STATEMENTS MADE HEREIN ARE TRUE IN EVERY RESPECT. SIGNATURE OF EMPLOYER/ HUMAN RESOURCES DIRECTOR (BLUE INK) DATE APPLICANT S SIGNATURE (BLUE INK) DATE SIGNATURE OF RESPONSIBLE SUPERVISOR (BLUE INK) DATE YOU MUST PROVIDE THE FOLLOWING INFORMATION FOR THE RESPONSIBLE SUPERVISOR: PLEASE PRINT SUPERVISORS FULL NAME ADDRESS OF RECORD *LICENSE NUMBER OR CREDENTIAL NUMBER CITY, STATE, ZIP CODE PHONE NUMBER *IF YOU HOLD A VALID AND CURRENT PROFESSIONAL CLEAR, CLEAR, OR LIFE CLINICAL OR REHABILITATIVE SERVICES CREDENTIAL IN LANGUAGE, SPEECH, AND HEARING, A LICENSE IN ANOTHER STATE, OR ASHA CERTIFICATION YOU MUST ATTACH PROOF. REV 10/14

8 REQUEST FOR LIVE SCAN SERVICE Applicant Submission ORI: Type of Application: (check one) Employment License, Certification, Permit Volunteer Code assigned by DOJ Job Title or Type of License, Certification or Permit: Agency Address Set Contributing Agency: Agency authorized to receive criminal history information Mail Code (five-digit code assigned by DOJ) Street No. Street or PO Box Contact Name (Mandatory for all school submissions) City State Zip Code Contact Telephone No. Name of Applicant: (Please print) Last First MI AKA s: Last First CDL No. DOB: SEX: Male Female Misc. No. BIL Agency Billing Number (if applicable) HT: WT: Misc. No. EYE Color: HAIR Color: Home Address: (Applies only if Youth Org/HRA or Public Utility submission) POB: SOC: Street or PO Box City, State and Zip Code Your Number: OCA No. (Agency Identifying No.) If resubmission, list Original ATI No. Level of Service DOJ FBI Employer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only) Employer Name Street No. Street or PO Box Mail Code (five digit code assigned by DOJ) City State Zip Code Agency Telephone No. (Optional) Live Scan Transaction Completed By: Name of Operator Date Transmitting Agency ATI No. Amount Collected/Billed BCII 8016 (Rev10/98) ORIGINAL-Live Scan Operator; SECOND COPY-Requesting Agency; THIRD COPY-Applicant