Personal / Contact Information

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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, 2018. The fee for the background check is $44.50. You may combine these fees and submit one $184.50 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) 673-0220 (971) 673-0226 fax 800 NE Oregon St Ste 407 Portland OR 97232 www.bspa.state.or.us

First Middle Last

Social Security Number (SSN) is required per

Oregon Statute. Your email 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 MAY NOT start employment before receiving your license.

Personal / Contact Information

Name:

Other Names Used: (Maiden, etc.) : Gender: Male Female SSN: Date of Birth: Employer:

City State Zip Code

Address: Street1:

City State Zip Code

Street2:

Oregon Employment Offer (if any) Expected Start Date: ______________ Email:

City State Zip Code

Current Work Address - Title: ________________________________(Or mark “not employed”) Employer:

Address:

Home Phone Number Cell Phone Number

Work Phone Number Home Address - Required

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Revised December 2015 Page 2

Satisfying License Requirements

Education

I received my 90 quarter (or 60 semester) hours from:

Was your academic work conducted in English? Yes No

Supervisor Information (Who will be supervising you?)

Name:

First MI Last

Oregon SLP License/Permit #:

You will need to have official transcripts sent from your educational institution(s).

Your SLP supervisor must hold an active SLP license from this Board, or meet addi-tional 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 cur-rently working as an SLPA, write “NOT EMPLOYED” 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 Signature Date

Supervision Affidavit

The above named supervisor must read and initial the following statements, certifying that they will abide by them.

Sup. Initials

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 calcula-tions 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 super-vised. A minimum of 10% of hours spent in clinical interaction must be directly supersuper-vised. 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

re-quirements stated in 335-095-0040 must be assigned.

5 The caseload of the supervising SLP must allow for administration, including SLPA

supervi-sion, 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 documen-tation 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.

Institution Technical/General? Dates Attended # of Credits Requested Transcripts

 Yes  Not Yet  Yes  Not Yet  Yes  Not Yet

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Criminal / Adverse Professional History

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.

Signature of Applicant Date

You 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:

http://www.oregon.gov/ bspa/Pages/rules.aspx

Have you ever been arrested for any reason?  Yes*  No

Have you ever been charged in court with any violation of the law (other than

minor traffic violations)?  Yes*  No

Have you ever been convicted of any violation of the law

(other than minor traffic violations)?  Yes*  No

Have you ever been the subject of a complaint reported to

another licensing agency?  Yes*  No

Have you ever been the subject of any disciplinary

investigation or action by another licensing agency?  Yes*  No Have you ever voluntarily surrendered or resigned a

professional license/certificate?  Yes*  No

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.

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: Language Proficiency:

Asian/Pacific Islander American Indian/Alaskan Native Other: _______________

Black (not Hispanic) White (not Hispanic)

Hispanic Hawaiian/Pacific Islander

Are you bilingual? Yes No

Languages: ____________________________

* If you answer yes to any of the questions, please include a copy of the related court proceedings, police reports and/or Board order for each conviction and/or disciplinary action. You must also attach a written narrative (your own personal

statement) describing 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 1st₎ _{Position Title} _{City, State} _{Dates of}

Employment

Please list all professional licenses you hold now or have ever held. Attach additional pages if necessary. You 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?

 Yes

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Supplement 1—Professional Development Hours

You will need to demonstrate that you are current in your professional knowledge through

professional development accrued. Follow the flow chart below.

I hereby certify that the above information is true and correct to the best of my knowledge.

Signature of Applicant Date



No - Go to (2)

(1) When did you complete your clinical fieldwork? ___________ Was that less than 12 months ago?

Title of Activity Date Completed # of Total Hours 1 PD Hr= 60 mins Approved Activity? (Y/N) Approved Topic? (Y/N) Approved Sponsor? (Y/N) Special Board Approval Needed? (Y/N)

Examples: OSHA Conference

Speechpathology.com : Dysphagia 101

Autism Workshop– Gorge ESD —Non-employee

10/1/2012 11/8/2013 8/7/12 6.5 2 1.5 Y Y N Y Y N Y Y N No No Y,#13-755

(2) Do you have 7.5 hours or more of acceptable activities completed within the last 12 months?



Yes

-

Stop.

No need to report PD hours now. You will need to meet PD

hour requirements to renew your license on or before December 31, 2017.



Yes

-

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.

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Triple Test (ATS) Quick Guide – Accepted Without Special Approval

Activities Accepted

Without Special Approval

Topics Accepted

Without Special Approval

Sponsors Accepted

Without Special Approval

learning such as academic

courses, classes,

conferences, programs, and

workshops, that are

presented electronically, in‐

person, or in other formats

accompanied by

examination and sponsored

by a Board‐recognized

professional organization in

audiology or speech‐

language pathology

language and hearing disorders

speech‐language and hearing services

training, professional ethics, professional

regulation, and professional leadership

and management

research activities, and developing and

implementing evidence‐based practices

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

marketing issues directly related to clinical

service delivery

speech/language/hearing assessment and

intervention

prevention of medical errors

Board Registry subject code list published

by ASHA in 2008 and as revised

knowledge necessary to effectively

provide SLP or audiology services to

students in a pre‐K to high school setting

speech‐language‐hearing

organizations recognized by

ASHA, AAA, or ABA

providers approved by ASHA,

AAA, or ABA

provides to hearing aid

specialists, or approves for

continuing education for its

licensed hearing aid

specialists

for Speech‐Language

Pathology & Audiology for

programs it provides to its

licensees

education accredited by an

appropriate national, state or

regional body or approved by

the Board, for academic

courses

American Heart Association

for cardio‐pulmonary

resuscitation or basic life

support

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.

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Triple Test (ATS) Quick Guide –Accepted ONLY With Special Approval, Or NOT Accepted

Activities Accepted

With Special Approval

Topics Accepted

With Special Approval

Sponsors Accepted

With Special Approval

reviewed professional

journals

content is directly related or falls into the

above topics, special approval may be

requested

home health care companies,

skilled nursing facilities,

hospitals, or universities, for

programs for non‐employees

and public

development providers or

sponsors not listed above

Note: If the activity has a check mark in ANY column above, it requires special approval.

Activities

Not Accepted

Topics

Not Accepted

students or clinical fellows

boards or committees

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

presentations or research

activities

articles

listed as accepted

performance and practice of SLP or

audiology

topics.

Some examples of non‐accepted topics

might include policies and procedures,

employee benefits, generic software skills

such as email and word processing. These

topics are appropriate for staff meetings

but are not appropriately PD.

other situations in which

there is no sponsor

Note: If the activity has a check mark in ANY column above, it cannot be counted for PD.

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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.

Section A - Instructions:

To schedule a fingerprinting appointment, please follow these simple instructions:

1. Visit

www.FieldprintOregon.com

2. Click on the “Schedule an Appointment” button.

3. Enter an email 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 877-614-4364 or

customerservice@fieldprint.com

.

Section B – Information to submit with your application

Applicant Name: ____ _____________

Fieldprint Location: __________________

Date Prints Taken: __________________

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Revised December 2015 Page 1 State Seal Here

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. You 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.

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 97232 Jurisdiction (State/Agency): ____ _____________ Licensee Name: __________________ License #: Initial Date: Expiration Date:

Any Legal or Disciplinary action on this license?



Yes*



No * Please provide documentation.

Verified by Name (print): ____ Date: ______

Signature: ____________________________ Title: _________________________________

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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. Your initials indicate that you met and discussed these ratings.

Board of Examiners For Speech-Language Pathology & Audiology (971) 673-0220 (971) 673-0226 fax 800 NE Oregon St Ste 407 Portland OR 97232 www.oregon.gov/bspa

Fieldwork Participant Name:

Area of Examination

Rating #1

Date:

Rating #2

Date:

Rating #3

Date:

Rating #4

Date:

Knowledge of universal health and safety precautions.

 Does Not Meet  Meets

 Exceeds

 Exceeds 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

 Exceeds

 Exceeds Ability to follow a therapy plan over

time.

 Exceeds

 Exceeds Completes individual therapy

sessions.

 Exceeds

 Exceeds Completes group sessions with

behavior management.

 Exceeds

 Exceeds Collects data on therapy sessions.  Does Not Meet

 Meets  Exceeds

 Exceeds

 Exceeds Demonstrates understanding and

ability to address client confidentiality issues.

 Exceeds

 Exceeds 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 #

___________________________________________

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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.

Board of Examiners For Speech-Language Pathology & Audiology (971) 673-0220 (971) 673-0226 fax 800 NE Oregon St Ste 407 Portland OR 97232 www.oregon.gov/bspa

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.

Date

Activity

_{Time (Hrs)}

Length of

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:

Supervisor’s Name (Print) Clinical Fieldwork Site

Supervisor’s Signature Date Oregon License # or ASHA Certification #