Speech Language Pathologists and Audiologists Forms
On this page:
Speech-Language Pathologists
| Title | Document Number |
|---|---|
| Speech-Language Pathology Application (including ASHA Waiver) (PDF) | SPA006 |
Intern in Speech-Language Pathology Upgrade to Speech-Language Pathologist
| Title | Document Number |
|---|---|
| Upgrade Intern in Speech-Language Pathologist Application (PDF) | SPA010 |
| Speech-Language Pathology Report of Completed Internship Form (PDF) | SPA015 |
Intern in Speech-Language Pathology
Assistant in Speech-Language Pathology
Supervision Forms for Assistant in Speech-Language Pathology
| Title | Document Number |
|---|---|
| Speech-Language Pathology Supervisory Responsibility Statement (SRS) (PDF) | SPA013 |
| Supervision Log for the Licensed Assistant in Speech-Language Pathology (PDF) | SPA029 |
Clinical Deficiency Plan for Assistant in Speech-Language Pathology
Audiologists
| Title | Document Number |
|---|---|
| Audiology Application (including ASHA or ABA Waiver) (PDF) | SPA005 |
| Audiology Intern Plan and Agreement of Supervision (PDF) | SPA014 |
| Intern in Audiology Course Work and Clinical Experience Form (PDF) | SPA-LIC-020-E |
Intern in Audiology
Intern in Audiology Upgrade to Audiologist
| Title | Document Number |
|---|---|
| Upgrade Intern Audiologist Application (PDF) | SPA004 |
| Report of Completed in Internship in Audiology Form (PDF) | SPA-LIC-019-E |
Assistant in Audiology
| Title | Document Number |
|---|---|
| Assistant In Audiology Application (PDF) | SPA001 |
| Report of Completed Training for an Assistant in Audiology (PDF) | SPA011 |
| Assistant in Audiology Supervisory Responsibility Statement (SRS) (PDF) | SPA-LIC-018-E |
Other Forms
SPA026 Speech-Language Pathology and Audiology Notice of Change and Duplicate License Request (PDF)
SPA027 Speech-Language Pathology and Audiology License Verification Form (PDF)
Occupational License Application Claiming to Have No Social Security Number
Disciplinary Action Questionnaire (PDF)
Criminal History Questionnaire (PDF)
Military Service Member, Military Veteran, or Military Spouse Supplemental Application (PDF) - see Military Spouse Frequently Asked Questions
Request to Executive Director for Expired License Renewal (PDF)