APPLICA A ATION FOR THE CERTIF F E FICATE OF CLIN NICAL COMPET C TENCE IN SPEEC CH-LAN NGUAGE PATHO OLOGY

2005 STANDA S ARDS

Inst tructions 1 Applicant applying within three years of graduation from a CAA-accredited program need to complete 1. ts w y m o and subm the follow mit wing: The four-page application form (page 13 to be completed a e n es and signed b the applicant; page 4 by to be comple o eted and signed by the director o the graduate acade of emic progra am, and must be the original pa m age with the ASHA log from the application (blank or a go e n altered co opies will not be accepte ed). All four pages mus be subm itted togeth r st her; partial applications will delay processing. w An official gra aduate transcript which verifies the d v date and deg gree awarded. Full payment in the form of a check or charge aut o thorization. Charges acc cepted are Visa, MasterCard, or Discover. M o

ts m hree years af fter graduati ion from a C CAA-accredite program need to ed Applicant applying more than th complete and submit the followin e t ng: The four-page application form (page 13 to be completed a e n es and signed b the applicant; page 4 by o eted and signed by the director o the graduate acade of emic progra am, and to be comple must be the original pa m age with the ASHA log from the application (blank or a go e n altered co opies will not be accepte ed). All four pages mus be subm itted togeth r st her; partial applications will delay processing. w Official graduate and undergraduate transcripts s O t showing all c course work completed fo or ce ertification and the dates and degree awarded. a s es Full payment in the form of a check or charge aut o thorization. Charges acc cepted are Visa, MasterCard, or Discover. M o

2 Please co 2. omplete the application form in black ink. f k 3 Applicatio must bear the origin signatures of both the applicant a 3. ons nal e and the direc ctor of the graduate academic program. Applications without original signatur c A w res are consi idered as inc complete and will delay d the award of certifica ation. 4 Please make and reta copies of all documen prior to s 4. ain f nts submitting th hem to the A ASHA Nation Office. nal Copies of documents are not available once certification is awarded. f c 5 Please ca 5. arefully revie the applic ew cation prior to submissio n to be certa that all s t ain sections have been e complete Incomple applicatio ed. ete ons will be re eturned to th applicant. he . s 6 All applic 6. cations and payments mu be sent to the PO Bo address as listed on th top of the application p ust t ox he e form.

Application processing time is ap A g pproximate ly 4 to 6 we eeks from t the date all required materials are received. e

ASHA2005SLPStanda ardsforClinicalCertification

Amer rican Speech-Language-H Hearing Assoc ciation PO B Box 1160 #31 Rockville, MD 20849 13,

For Intern Use Only rnal ly Acco ount #______ ____________ _ Most Recen CCC Date__ nt ___/_____/_____ _ Expiration Date_____/__ n _____/________ _

APPLIC CATION FOR CERT F TIFICATIO AND M ON MEMBERS SHIP 2005 SPEECH5 -LANGUA AGE PATH OLOGY ST TANDARD DS
Please read all applicatio instructions before com on mpleting and s submitting th form. his AL sections must be comp LL m pleted and ori iginal signatu ures must appear on the a application. P Please be sur that you ar using the appropriate application fo the standar re re a a or rds under wh hich you wish to apply. I. BACKGRO OUND INFO ORMATION (Sections 1-5) (1) Perso onal Inform mation Ms Mrs Mr Miss Dr Name: Fi irst Middle Prev vious Last

Mailing Addres M ss: City S State Zip

Social Sec curity Numbe ________ er: ___________ ___________ ________ Daytime phone numbe p er: E-mail address: (2) Application Cate egory I am appl lying for (Plea [] the appropriate category): ase a [ ] Membersh and Certification in Spe hip eech-Languag Pathology ge y [ ] Certificatio in Speechon -Language Pa athology (wit thout Membership) My presen affiliation with ASHA is (Please [] the appropria category) nt w ate ): [ ] None [ ] ASHA Cert tified Member in Audiology r y I am a former membe of ASHA er I am a former ASHA certificate hold der [ ] Yes [ ] Yes [ ]A ASHA Membe only er [ ]A ASHA Certific cate Holder in Audiology n [ ]N No [ ]N No [ ] Yes [ ] No o [ ] NSSLHA Member (NSSLHA Account Number ___ M ___________ ________) Evening p phone numbe er: Fax numb ber:

I am a former applican for membe nt ership and/or certification r

(3) Educ cation Offic transcript must be su cial ts ubmitted by a applicants. all Ins stitution Code (See appendix) Ex. R R0291 Education n Began Mo Yr Y 08 200 09 Educa ation Completed Yr Mo 05 2012

Institution Name Uni iversity, USA A

Major S SLP

Date Degre ee Awarded 06/12/2012

Degree MS

1 ASHA2005SLPStanda ardsforClinicalCertification


American Speech-Lang guage-Hearin Association ng n PO Box 1160 # O #313, Rockvil lle, MD 20849 9

Nam of Applica me ant:

(Please print t)

(4) Exam mination Inf formation I have tak ken and pass sed the Praxis Series exam s mination in sp peech-langua age pathology and have lis y sted ASHA as s a score re ecipient. (Please [ the approp ] priate respon nse): [ ] yes [ ] No Note: On scores rec nly ceived directly from ETS are accepted f certificati y a for ion. (5) Discl losure Infor rmation 1. en ; ntered a plea of guilty or n nolo contende ere to Have you ever bee convicted; been found guilty; or en a. any misde emeanor involving dishone esty, physica l harm to the person or property of an e nother, or a threat of physical harm to the perso or propert of another or p m on ty b. any felony y? Check one [ ] Yes [ ] No If yes explain fully including the nature an date of the offense(s); your age at time of conviction or s, y, t nd e plea; whether inca arceration, fin or probation was impo ne, osed; rehabilitation; and a any other rele evant factors s that you would like ASHA to co y e onsider. Pleas submit a c se certified copy of court reco or docket entry of the ord t finding, conviction and/or plea or, if applic n, a, cable, a certif fied copy from a governm m mental agency y(s) that includ the pleas and/or convictions and demonstrates remediation. Please use a separate piece of paper des r if necessary.

Note: Checking ye to any of the above wil not automa es t ll atically preclu ude certificati ion and/or m membership. All rel levant factors will be cons s sidered. An ap pplicant may file with ASH at any tim a certific y HA, me, cate demo onstrating tha the underly at ying finding, plea, or judg p gment of conv viction has be een modified, reversed, , vacat ted, or set asi ide (on appea al). 2. Are you presently indicted on or charged with (a) one or more misde o r emeanors inv volving dishon nesty, physical harm to the person or property of another, or t t r threat of phys sical harm to the person o property of o or o anoth her; or (b) on or more felonies? ne Check one [ ] Yes [ ] No

If yes explain fully including the nature an date of the alleged offe s, y, t nd e ense(s), the c court of jurisd diction where e the in ndictment(s) or charges ar pending, and any other relevant fac re a r ctors that you would like A u ASHA to consid der. Please use a separate piece of paper if necessa e ary.

Note: Checking ye to the que es estion above will not autom matically pre eclude certific cation and/or membership p. All rel levant factors will be cons s sidered. An ap pplicant may file with ASH at any tim a certific y HA, me, cate demo onstrating tha the indictm at ment(s) or cha arge(s) have been dismiss sed or otherw wise resolved d.

2 ASHA2005SLPStanda ardsforClinicalCertification


American Speech-Lang guage-Hearin Association ng n PO Box 1160 # O #313, Rockvil lle, MD 20849 9

Nam of Applica me ant:

(Please print t)

3.

Have you ever bee disciplined or sanctione other tha n for insufficient professio en d ed, onal or contin nuing educa ation, by any professional association, professional licensing aut thority or boa ard, or other professional regula atory body? Check one [ ] Yes [ ] No If yes explain fully including the nature an date of the offense(s); rehabilitation; restitution and any s, y, t nd e n; other relevant fact tors that you would like ASHA to consi A ider. Please s submit a cert tified copy of docum mentation fro the profes om ssional agenc cy(s) that incl ludes the discipline or san nctions impos sed and demo onstrates, if applicable, rem a mediation. Pl lease use a s eparate piece of paper if necessary. e

Note: Checking ye to the que es estion above will not autom matically pre eclude certific cation and/or membership p. All rel levant factors will be cons s sidered. An ap pplicant may file with ASH at any tim a certific y HA, me, cate demo onstrating tha the underly at ying finding, discipline, or sanction has been modif r s fied, reversed vacated, or d, r set as side. II. Affidavit (Section 6) ts 6 A. I affir that all of the informat rm tion provided on this appli ication is true and accurat and fully r e te responsive to the qu uestions aske ed. B. I have read and ag e gree to abide by the Code of Ethics of the American Speech-Lan e e nguage-Hear ring Assoc ciation. C. I agre to abide by all standard required to maintain m certificatio including payment of a ee y ds o my on, annual fees and participation in continuing professional developmen t activities, a p and I underst tand that, onc certified, ce my ce ertification status may be made available to the pu blic. Signature e: Date:

3 ASHA2005SLPStanda ardsforClinicalCertification


American Speech-Lang guage-Hearin Association ng n PO Box 1160 # O #313, Rockvil lle, MD 20849 9

me ant: Nam of Applica (Please pr rint)

20 005 Stand dards for Clinical Ce C ertificatio n in Speec ch-Language Patho ology Verificatio by Prog V on gram Director
Pleas respond to each question. The appli se o icant must ha ave met each standard in order to app for certific h ply cation. Yes s Yes s Yes s Yes s Yes s Yes s No No No No No No Has a maste ers or doctoral degree. A minimum of 75 semester credit hours were comple r s eted in a course of stu udy addressin the knowledge and ski lls pertinent to the field o speech-lang ng of guage pathology. (Std. I) Initiated and completed all graduate course work and graduate clinical prac d a c e cticum in an institution whose progr ram was accr redited by the Council on A e Academic Accreditation in Audiology a n and SpeechLanguage Pa athology (CAA (Std. I) A). Completed a course of st tudy (a minim mum of 75 se emester credi hours overall, including at least 36 it at the gradu uate level) tha includes ac at cademic cour rse work suff ficient in dept and breadt to achieve th th e the knowledge and skills outcomes. (Std. III) Has demons strated knowledge of the principles of b p biological scie ences, physic sciences, cal mathematics and social/ s, /behavior scie ences. (Std. III. A.) Has demons strated knowledge of basic human com c mmunication a and swallowing processes including s, their biologic cal, neurological, acoustic psychologic c, cal, developm mental, and li inguistic and cultural bases. (Std. III. B.) Has demons strated knowledge of the nature of spe n eech, languag hearing, a ge, and communication disorders an differences and swallow nd s wing disorder including t rs, the etiologies characteristics, s, anatomical/p physiological. Acoustic, ps sychological, developments, and linguistic and cultural correlates in the nine are noted in the standard. (Std. III. C. n eas t . .) Possesses kn nowledge of the principles and method of prevent t s ds tion, assessm ment, and inte ervention for people with communicati ion and swallowing disord ders. (Std. III D.) I. strated knowledge of the standards of ethical condu s uct. (Std. III. E.) . Has demons Has knowled dge of proces sses used in research and the integrati r ion of researc principles into ch evidence-based clinical practice. (Std. III. F.) p Has demons strated knowledge of contemporary pro ofessional iss sues. (Std. III. G.) Has demons strated knowledge about certification, s c specialty reco ognition, licensure, and other relevant t professional credentials. (Std. III. H.) ) Has complet ted a curriculum of academ and clinic education that follows an appropria sequence mic cal n ate of learning sufficient to achieve the sk s a kills outcome in Standard IV-G. (Std. IV. A.) es d Possesses sk kills in oral an written an other form of commun nd nd ms nication suffic cient for entr into ry professional practice. (St IV. B.) td. Has complet ted a minimum of 400 clock hours of s supervised cli inical experie ence in the pr ractice of speech-language patholo ogy, including 25 hours in clinical obse g ervation and 3 375 hours in direct client/patien contact. (S nt Std. IV. C.) Has complet ted at least 325 clock hours while enga aged in gradu uate study. (Std. IV. D.) Has been su upervised by individuals ho olding a curre ASHA Certificate of Cl ent linical Compe etence in the appropriate area of pract tice. The amo ount of super rvision was ap ppropriate to the student level of o s knowledge, experience, and competence, and was sufficient to ensure the w a s o welfare of the e client/patien populations (Std. IV. E.) nt s. Has gained knowledge an experience with individ k nd e duals from cu ulturally/lingu uistically dive erse backgrounds and with client/patient populations a s p across the life span. (Std. IV. F.) e The applican has met th academic programs req nt he p quirements fo demonstra or ating satisfac ctory performance through ong e going formative assessme of knowle ent edge and skill (Std. V. A.) ls.

Yes s Yes s Yes s Yes s Yes s Yes s Yes s Yes s Yes s Yes s

No No No No No No No No No No

Yes s Yes s

No No

The p program director or designee verifies that the student met each standard an has succes t h nd ssfully met th academic he programs require ements. Name of Program Dire P ector Signature e (Ple ease print) Title D Date

Date cour rsework and clinical practi icum requirem ments for AS SHA certificati ion were com mpleted 4 ASHA2005SLPStanda ardsforClinicalCertification