Personal / Contact Information

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1 Application for Speech-Language Pathology Assistant Certificate Fill out and submit this form if you are applying for the first time in Oregon for a Speech- Language Pathology Assistant (SLPA) certificate. To issue your certificate, we need to have: 1. This form (originals, no faxes or copies, please) completed in its entirety. 2. A check or money order payable to Oregon Speech Board for $75 is due now for application review. The licensing fee is $65 for a license that expires on January 30, The fee for the background check is $ ou may combine these fees and submit one $ check now for faster processing. 3. Official transcripts sent to us from your school(s) showing 45 quarter (30 semester) hours of general and 45 quarter (30 semester) hours of technical (SLP) credit. 4. Evidence of professional development within the last 12 months. (See Supplement 1) 5. Details of your fingerprint submission through FieldPrint, Inc.(see supplement 2). 6. Official Verifications of any licenses held in other jurisdictions. (See Supplement 3) 7. The SLPA Clinical Competency Checklist (See Supplement 4) 8. The SLPA Clinical Fieldwork Log (See Supplement 5) Board of Examiners For Speech-Language Pathology & Audiology (971) (971) fax 800 NE Oregon St Ste 407 Portland OR Personal / Contact Information Name: First Middle Last Other Names Used: (Maiden, etc.) : Gender: Male Female Street1: Street2: Employer: Address: Date of Birth: Home Address - Required Employer: SSN: City State Zip Code Current Work Address - Title: (Or mark not employed ) Address: Home Phone Number City State Zip Code Work Phone Number Cell Phone Number Oregon Employment Offer (if any) Expected Start Date: City State Zip Code Social Security Number (SSN) is required per Oregon Statute. our address will be used for Board correspondence and not shared with others. Check the box indicating which address you like to use for Board correspondence. This address will be printed on your license. Board rules require licensees to update contact information within 30 days of the change. Note: If you have a job offer in Oregon pending licensure, provide that address and planned start date. Remember you MA NOT start employment before receiving your license. Work Phone Number

2 ou will need to have official transcripts sent from your educational institution(s). Satisfying License Requirements Education I received my 90 quarter (or 60 semester) hours from: Institution Technical/ General? Dates Attended # of Credits Requested Transcripts es Not et es Not et es Not et Was your academic work conducted in English? es No our SLP supervisor must hold an active SLP license from this Board, or meet additional requirements if licensed by TSPC. See the Licensee Directory on our website. IMPORTANT: If you have multiple supervisors, make a copy of this page for each supervisor and attach all of the supervisor sheets to this application. If you are not currently working as an SLPA, write NOT EMPLOED across this section. When you begin work as an assistant, be sure to submit an SLPA Supervision Change Form (available on the Forms page of our website). All added or deleted supervisors must be reported within 30 days of the change. Supervisor Information (Who will be supervising you?) Name: First MI Last Oregon SLP License/Permit #: Supervision Affidavit The above named supervisor must read and initial the following statements, certifying that they will abide by them. 1 For the first 90 calendar days of licensed employment, with a given employer, a minimum of 30% of all the time an assistant is providing clinical interaction must be supervised. A minimum of 20% of hours of clinical interaction must be directly supervised. These calculations must be made monthly. 2 Subsequent to the first 90 calendar days of licensed employment with a given employer, a minimum of 20% of all the time an assistant is providing clinical interaction must be supervised. A minimum of 10% of hours spent in clinical interaction must be directly supervised. These calculations must be made monthly. 3 The supervising SLP must be able to be reached throughout the work day. A temporary supervisor may be designated as necessary. 4 If the supervising SLP is on extended leave, an interim supervising SLP who meets the requirements stated in must be assigned. 5 The caseload of the supervising SLP must allow for administration, including SLPA supervision, evaluation of clients and meeting times. SLPAs may not have a caseload; therefore, all clients are considered part of the SLP s caseload. The supervising SLP is responsible to make all diagnostic and treatment related decisions for all clients on the caseload. 6 The supervising SLP may not supervise more than the equivalent of 2 full-time SLPAs. 7 The supervising SLP must co-sign each page of records. 8 Supervision of SLPAs must be documented. (a) Documentation must include the following elements: date, activity, clinical interaction hours, and direct or indirect supervision hours. Clinical logs documenting supervision must be completed and supervision hours calculated for each calendar month for each caseload. Each entry should be initialed by the supervising SLP. Each page of documentation should include the supervising SLP s signature and license numbers issued by this Board and/or the Teacher Standards and Practices Commission if applicable. Supervision documentation must be retained by the SLPA for 4 years. (b) Documentation must be available for audit requests from the Board. Sup. Initials Supervisor Signature Date Revised December 2015 Page 2

3 Criminal / Adverse Professional History Answer all questions below with yes or no. Failure to answer truthfully may result in denial of your application and/or disciplinary action by the Board. * If you answer yes to Have you ever been arrested for any reason? es* No any of the questions, Have you ever been charged in court with any violation of the law (other than please include a copy of es* No minor traffic violations)? the related court proceedings, police Have you ever been convicted of any violation of the law es* No reports and/or Board (other than minor traffic violations)? order for each Have you ever been the subject of a complaint reported to conviction and/or es* No another licensing agency? disciplinary action. ou must also attach a Have you ever been the subject of any disciplinary es* No written narrative (your investigation or action by another licensing agency? own personal Have you ever voluntarily surrendered or resigned a statement) describing es* No professional license/certificate? the surrounding facts Work Experience List for the past 5 years, adding sheets if needed If employed by a staffing agency, list the agency as your employer, but list the city/state of your job location(s). Employer (most recent 1 st ) Position Title City, State Dates of Employment Licensing in Other Jurisdictions List all that you hold now or have ever held Please list all professional licenses you hold now or have ever held. Attach additional pages if necessary. ou must request a letter of good standing from every state or agency that has issued you a professional license, including Oregon Teacher Standards and Practices Commission or other education-related agencies. See Supplement 2. State/Agency Lic # Expiration Date Requested? Ethnicity / Language Proficiency Provision of this information is voluntary. If you choose not to provide the information, it will have no effect on the acceptance or processing of your application or renewal. Ethnic/Racial Background: Asian/Pacific Islander Black (not Hispanic) American Indian/Alaskan Native White (not Hispanic) Other: Hispanic Hawaiian/Pacific Islander Certification and Affidavit I have read the provisions of the Oregon Law (ORS 681) and Oregon Administrative Rules (OAR 335). I agree to abide by all the Laws and Rules pertaining to my license. I understand that the burden of proof in meeting the requirements for licensure is upon myself and not the Board. I agree to be responsible for the collection and accuracy of required materials. Affidavit of Applicant I,, depose and say that all of the above statements are true and correct; that I am the person described and identified above and on all attached documents. Language Proficiency: es es Are you bilingual? es No Languages: ou are expected to read and comply with Oregon Revised Statute (ORS) 681 and Oregon Administrative Rules (OAR) 335. The ORS and OARs can be found from our Rules/ Statutes page on our website: bspa/pages/rules.aspx Signature of Applicant Date Revised December 2015 Page 3

4 Supplement 1 Professional Development Hours ou will need to demonstrate that you are current in your professional knowledge through professional development accrued. Follow the flow chart below. (1) When did you complete your clinical fieldwork? Was that less than 12 months ago? es - Stop. No need to report PD hours now. ou will need to meet PD hour requirements to renew your license on or before December 31, No - Go to (2) (2) Do you have 7.5 hours or more of acceptable activities completed within the last 12 months? es - Complete the log below and attach certificates of attendance or completion. Applications submitted without proper documentation of professional development will not be processed. For each activity, make sure it is an accepted type of Activity (A), on an accepted Topic (T), by an accepted Sponsor (S); or if it will require special approval. See the ATS Triple Test Guide on the next pages. Click here or go to our Forms page for a special approval form. If you need more space on the log below, you may copy this page and submit multiple copies. Title of Activity Date Completed # of Total Hours 1 PD Hr= 60 mins Approved Activity? (/N) Approved Topic? (/N) Approved Sponsor? (/N) Special Board Approval Needed? (/N) Examples: OSHA Conference Speechpathology.com : Dysphagia 101 Autism Workshop Gorge ESD Non-employee 10/1/ /8/2013 8/7/ N N N No No,# I hereby certify that the above information is true and correct to the best of my knowledge. Signature of Applicant Date

5 Triple Test (ATS) Quick Guide Accepted Without Special Approval Activities Accepted Without Special Approval Organized programs of learning such as academic courses, classes, conferences, programs, and workshops, that are presented electronically, inperson, or in other formats Self study courses accompanied by examination and sponsored by a Board recognized professional organization in audiology or speechlanguage pathology Topics Accepted Without Special Approval Assessment and intervention for speechlanguage and hearing disorders Speech, language and hearing science Service delivery issues associated with speech language and hearing services Issues in pre professional and professional training, professional ethics, professional regulation, and professional leadership and management Planning, conducting and interpreting research activities, and developing and implementing evidence based practices Cultural and linguistic diversity in education, training, service delivery, and public policy associated with speech, language, and hearing, including the study of foreign language when needed for direct clinical practice Sponsors Accepted Without Special Approval ASHA, AAA, or ABA OSHA, OAA, or other state speech language hearing organizations recognized by ASHA, AAA, or ABA Continuing education providers approved by ASHA, AAA, or ABA OHLA for programs that it provides to hearing aid specialists, or approves for continuing education for its licensed hearing aid specialists Oregon Board of Examiners for Speech Language Pathology & Audiology for programs it provides to its licensees Business practices, regulatory policy, and marketing issues directly related to clinical service delivery Psycho social issues associated with speech/language/hearing assessment and intervention Patient safety, clinical documentation and prevention of medical errors Other topics on the Continuing Education Board Registry subject code list published by ASHA in 2008 and as revised Educational strategies and professional knowledge necessary to effectively provide SLP or audiology services to students in a pre K to high school setting Institutions of higher education accredited by an appropriate national, state or regional body or approved by the Board, for academic courses American Red Cross or American Heart Association for cardio pulmonary resuscitation or basic life support Public school districts, ESDs, home health care companies, skilled nursing facilities, hospitals, or universities, for programs provided for their employees. Note: If the activity has a check mark in EACH column above, it is accepted without special approval. If check marks are in only one or two columns, you may apply for special approval.

6 Triple Test (ATS) Quick Guide Accepted ONL With Special Approval, Or NOT Accepted Activities Accepted With Special Approval Publishing articles in peerreviewed professional journals Topics Accepted With Special Approval If there is a question about whether content is directly related or falls into the above topics, special approval may be requested Sponsors Accepted With Special Approval Public school districts, ESDs, home health care companies, skilled nursing facilities, hospitals, or universities, for programs for non employees and public Other formal professional development providers or sponsors not listed above Note: If the activity has a check mark in AN column above, it requires special approval. Activities Not Accepted Supervision of practicum students or clinical fellows Serving on professional boards or committees Attending staff meetings Performing volunteer work Reading or studying professional journals, unless a formal self study program that includes an exam to document satisfactory completion, and sponsored by a Board recognized professional association in audiology or SLP Teaching classes, making presentations or research activities Peer reviewing professional articles Any other activities not listed as accepted Topics Not Accepted If content does NOT directly relate to the performance and practice of SLP or audiology If content does not focus on accepted topics. Some examples of non accepted topics might include policies and procedures, employee benefits, generic software skills such as and word processing. These topics are appropriate for staff meetings but are not appropriately PD. Sponsors Not Accepted Informal study groups or other situations in which there is no sponsor Note: If the activity has a check mark in AN column above, it cannot be counted for PD.

7 Supplement 2 Fingerprint Background Check Per ORS Chapter 181 & OAR335 the Board requires applicants to undergo a state criminal history check and a national criminal history check, using fingerprint identification. The passing of a criminal background check does not guarantee the granting of a license. The Board contracts with Fieldprint, Inc. to collect and transmit electronically transmitted fingerprints. A $44.50 fee for the background check must be included along with your application fee. The applicant is responsible for any and all charges through Fieldprint. Board of Examiners For Speech-Language Pathology & Audiology (971) (971) fax 800 NE Oregon St Ste 407 Portland OR Section A - Instructions: To schedule a fingerprinting appointment, please follow these simple instructions: 1. Visit 2. Click on the Schedule an Appointment button. 3. Enter an address under New Users/Sign Up and click the Sign Up button. Follow the instructions for creating a Password and Security Question and then click Sign Up and Continue. 4. Enter the Fieldprint Code: FPBSPALicenseDAS Enter the following BSPA Codes: ORI #: OR026SLPA (used for all checks) OCA#: SLPA (used for all checks) 5. Enter the contact and demographic information required by the FBI and schedule a fingerprint appointment at the location of your choosing. 6. At the end of the process, print the Confirmation Page. Take the Confirmation Page with you to your fingerprint appointment, along with two forms of identification. 7. If you have any questions or problems, you may contact the Board office or the Fieldprint customer service team at or customerservice@fieldprint.com. Section B Information to submit with your application Applicant Name: Fieldprint Location: Date Prints Taken: (Please allow one week for processing before inquiring on the results of the background check)

8 Supplement 3 Verification of Licensure in Good Standing Each applicant must request a verification of licensure in good standing from each jurisdiction (state licensing board or teacher/educator certification agency) for each professional license or certification you have ever been issued. ou may use this form, or a form the other board/ agency provides, as long as the same information is provided to this Board. Note: Many boards/agencies charge the applicant for this service. The applicant is responsible for paying such fees and for facilitating the request. The Oregon Board cannot issue your license until this information is received directly from each board/agency. Board of Examiners For Speech-Language Pathology & Audiology (971) (971) fax 800 NE Oregon St Ste 407 Portland OR Section A For Applicant to Complete Please complete this section and forward to the jurisdiction of licensure for them to complete and return to us. Name: License # for the below Jurisdiction: I,, authorize the release of information from the jurisdiction below to the Oregon Board of Examiners for Speech-Language Pathology & Audiology to determine my fitness for an Oregon license. Signature Date Section B For Licensing Entity to Complete The licensee below has applied for a license in Oregon and indicates that have been licensed in your jurisdiction. Please fill this form out, sign, date and affix your seal to it, returning to us at: Verifications Oregon Speech Board 800 NE Oregon St, Ste 407 Portland, OR Jurisdiction (State/Agency): Licensee Name: State Seal Here License #: Initial Date: Expiration Date: Any Legal or Disciplinary action on this license? es* No * Please provide documentation. Verified by Name (print): Date: Signature: Title:

9 Supplement 4 Speech-Language Pathology Assistant (SLPA) Clinical Competency Checklist The clinical fieldwork supervisor must complete the ratings below for each rating period that is, after each 25 hours of clinical interaction time. our initials indicate that you met and discussed these ratings. Fieldwork Participant Name: Area of Examination Rating #1 Date: Rating #2 Date: Rating #3 Date: Board of Examiners For Speech-Language Pathology & Audiology (971) (971) fax 800 NE Oregon St Ste 407 Portland OR Rating #4 Date: Knowledge of universal health and safety precautions. Basic Knowledge of workplace policies. Choose work setting below. Public Schools / Early Childhood Programs Special Education Procedural Safeguards Private Practice / Clinic Settings Ethical standards, policies and procedure Hospital Setting Ethical standards, policies and procedure Ability to follow a therapy plan over time. Completes individual therapy sessions. Completes group sessions with behavior management. Collects data on therapy sessions. Demonstrates understanding and ability to address client confidentiality issues. Participant Initials 1st Qtr: 2nd Qtr: 3rd Qtr: 4th Qtr: Supervisor Initials 1st Qtr: 2nd Qtr: 3rd Qtr: 4th Qtr: Supervisor Signature Date Oregon License # or ASHA Certification # Supervisor Name (Print) Site (Print)

10 Supplement 5 SLPA Clinical Fieldwork Log Each fieldwork participant must complete at least 100 hours of clinical interaction, defined as actively participating in or leading individual, small group, or classroom therapy sessions. Clinical interaction must be directly supervised 100% of the time. Also, each fieldwork participant must meet for a minimum of 2 hours with their supervisor for every 25 hours of clinical interaction, for a total of 8 hours. Meetings are for assessment, consultation and coaching regarding SLPA skills. Hours must be logged as in the examples below; assessments must be documented on the SLPA Clinical Competency Checklist form. Clinical interaction means: active participating in or leading individual, small group or classroom therapy sessions. Clinical interaction does NOT mean: passive observations, clerical tasks, materials preparation or meetings with your supervisor. Board of Examiners For Speech-Language Pathology & Audiology (971) (971) fax 800 NE Oregon St Ste 407 Portland OR Date Activity Length of Time (Hrs) Supervisor s Initials 3/31/14 Small group session articulation 1.0 gjk 4/14/14 Consultation with supervisor and first 25-hour assessment 1.0 gjk Total Hours Logged on this Page: Fieldwork Participant s Name (Print) Signature Date Supervisor s Name (Print) Clinical Fieldwork Site Supervisor s Signature Date Oregon License # or ASHA Certification #