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INSTRUCTIONS FOR TEMPORARY PARAPROFESSIONAL
LICENSURE AS AN APPRENTICE IN SPEECH-LANGUAGE (ASL)
Application must be complete or it will be returned. All forms and documentation requested are to be completed and returned as one complete packet.
_____________________________________________________________________________________________
The information you supply on this application will be used to determine your eligibility for licensure. You must supply all the information requested. Omission of any information may result in our inability to process your application. Your completed application will be used by authorized personnel of the board and may be transferred to other governmental or law enforcement agencies. It cannot be returned to you, but you may gain access to the information by contacting the board office at P.O. Box 25101, Santa Fe, New Mexico 87505.
← Read the entire application before you begin to answer any questions so you understand exactly what information is being requested.
← Answer all questions completely. The burden of proof in satisfying the board that you are eligible for licensure is upon you.
← Signature on application must be notarized.
← All documentation submitted must be notarized or certified as true and correct copies of the originals.
← Previously licensed applicants who failed to renew as required must reapply as a new applicant, meet all applicable requirements, meet all continuing education requirements and pay the application fee, the renewal fee and the late penalty fee.
← The jurisprudence examination is part of the application and must be completed and signed. This exam covers the statutes and regulations.
← Include the fee of $60 ($50 licensure fee and $10 application fee) in the form of a check or money order payable to the Speech Language Pathology, Audiology and Hearing Aid Dispensing Practices Board (SLPAHAD). Applications received without fees will not be processed.
Licensure Fee $ 50.00
Application Fee $ 10.00
Total Fee $ 60.00
FEES ARE NONREFUNDABLE
If additional space is needed to complete any section, attach additional pages. All supporting documents must be received at the board office before the application can be approved.
|For Office Use Only | |
|Amount Received $ ___________16402 |Check Number: |
|Receipt Number: |License Number: |
|Date Issued : |Approved by Date : |
Type or print legibly in black ink.
| | | |COMPLETE IF LICENSED OR FORMERLY LICENSED IN ANY OTHER STATE. |
|Temporary Paraprofessional License as an Apprentice in Speech-Language (ASL) | | | |
| | | |License #: __________________________________________ |
|Submit these required documents: | | | |
|Official transcripts indicating Bachelor’s Degree; | | |State: ______________________________________________ |
|Original Verification of Employment form; | | | |
|Original Verification of Education form; and | | |Date Granted: _______________________________________ |
|Jurisprudence exam. | | | |
| | | |Expiration Date: _____________________________________ |
| | | |Address of Grantor: |
| | | | |
| | | |___________________________________________________ |
| | | | |
| | | |___________________________________________________ |
| | | | |
| | | |Phone: (_______) ____________________________________ |
**All licensing information provided is public information.**
|PRINT your name as you wish it to appear on your license. |
|NAME OF APPLICANT (Last, First, Middle) |DATE OF BIRTH |SOCIAL SECURITY NUMBER |
|BUSINESS ADDRESS (Number, Street, City, State, Zip) |Business phone |MAIL ALL CORRESPONDENCE TO MY: |
| | | |
| | |( Business Address |
| | |( Residence Address |
|MAILING ADDRESS (Number, Street, City, State, Zip) | |
|E-MAIL ADDRESS: |
EDUCATION
|UNDER-GRADUATE |Name of College / University |Major area |Years of Study|Degree |Graduation Date |
|& | |of study | | | |
|GRADUATE | | | | | |
|EDUCATION | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
If your Bachelor’s Degree is not in Speech-Language Pathology or Communication Disorders, you must have a minimum of 30 semester hours of credit in Communication Disorders.
You must be enrolled in a Master’s Degree program in Speech-Language Pathology or Communication Disorders and complete a minimum rate of nine (9) semester hours per year of graduate courses in Communication Disorders. A temporary paraprofessional license may not be renewed if the licensee has not been accepted into a Master’s Degree program within two years of initial licensure. Licenses must be renewed annually no later than July 30th and meet the education requirements as listed on 16.26.2.15 NMAC.
( I am enrolled in a Master’s level Communication Disorders program.
Date accepted: ____________ University
( I am in non-degree status taking coursework in Communication Disorders.
This is my _____ year of non-degree coursework. University
Anticipated date of completion of Master’s degree:
ANSWER THE FOLLOWING QUESTIONS
If you answer YES to any question, attach a complete and comprehensive explanation. The board may contact you later for additional information.
|(Yes |1. Have you ever used another name under which records may be filed concerning your application or your education, training or experience? If yes, |
|(No |print name used: |
|(Yes |2. Have you ever received a deferred prosecution, a deferred judgment or been convicted of or pled guilty to or pled nolo contendere to a felony in |
|(No |any state, territory, district of the United States or a foreign country? |
|(Yes |3. Have you ever pled guilty to or pled nolo contendere to or been convicted of driving under the influence (DUI) or driving while intoxicated (DWI)?|
|(No | |
|(Yes |4. Have you ever been denied a license or permission to practice or permission to take an examination to practice speech-language pathology or |
|(No |audiology in any state, country or territory? |
|(Yes |5. Has any disciplinary action ever been taken regarding your practice or any license you hold or have held to practice? Disciplinary actions |
|(No |include, but are not limited to, suspension, probation, practice limitations, reprimand, letter of admonition, censure, and any allegations currently|
| |pending. |
|(Yes |6. Have you ever voluntarily surrendered a license to practice in any other state or territory? |
|(No | |
|(Yes |7. Are you in arrears in court-ordered child support payments? |
|(No | |
I HEREBY CERTIFY that I have read and completed this application, that the information contained herein is true to the best of my knowledge, that I am not physically or psychologically dependent on alcohol or drugs, and that I understand that any falsification or misrepresentation made within this application may be grounds for denial of my application or action against my license. I hereby authorize the Regulation and Licensing Department and its agents to investigate any statements made by me in this application, including checking criminal, civil and administrative records. I declare under penalty of perjury that the statements made on this form are true and complete to the best of my knowledge.
I FURTHER CERTIFY that I have read the New Mexico Speech-Language Pathology, Audiology and Hearing Aid Dispensing Practices Act and the Rules and Regulations and fully understand that I bind myself to be governed by them.
SIGNATURE:
DATE:
State of: _________________________________
County of: ________________________________________
Before me on this day personally appeared the above named applicant who, being by me duly sworn upon oath, says that all the acts, statements and answers contained in this application are true and correct.
Sworn and subscribed to before me____________________________ on this _______ day of_________, 20_____
Notary Public:
My Commission Expires:
SEAL
VERIFICATION OF EMPLOYMENT AND SUPERVISION
FOR TEMPORARY PARAPROFESSIONAL LICENSE
AS AN APPRENTICE IN SPEECH-LANGUAGE (ASL)
PART I - EMPLOYMENT AND SUPERVISION
Name of Employer (school district or business): ______________________________________________
Address: _____________________________________________________________________________
City: _______________________ State: __________________ Zip: _________ Phone: ______________
Name of Worksite Assignment (if other than above): __________________________________________
Name of Speech-Language Pathology Supervisor: ____________________________________________
Beginning Date of Supervision: _________________ Ending Date of Supervision: __________________
I hereby certify that I am the SLP supervisor assigned to the applicant listed above and that I will be supervising this individual at all assigned worksites. My total supervision will be completed as follows:
← A minimum of 10% of contact time must be under direct supervision.
← A minimum of 10% of indirect contact time must be monitored.
I acknowledge that I am aware I am legally responsible for the caseload assigned to the ASL.
Supervisor’s Signature: _________________________________________ License # ______________
PART II - TO BE COMPLETED BY APPLICANT’S CURRENT EMPLOYER
Name of Applicant: ______________________________________________ Date: _________________
Address: ____________________________ City: _______________ State: __________ Zip: _________
This is to verify that _________________________________________ is an employee in good standing.
(Employee name)
I confirm that the above named employee will engage in the following performance responsibilities.
Check all that apply.
( Screen speech-language and/or hearing abilities;
( Conduct treatment programs and procedures that are planned, selected and/or designed by the Supervising Speech-Language Pathologist;
( Prepare written daily plans based on the overall intervention plan designed by the Supervising Speech-Language Pathologist;
( Record, chart, graph or otherwise display data relative to the client performance and report changes in performance to the supervising SLP;
( Maintain daily service delivery/treatment notes and complete daily charges as requested;
( Assist the Speech-Language Pathologist during assessment of clients, such as those who are difficult to test;
( Perform clerical duties (including maintenance of therapy/diagnostic materials, client files) as directed by the supervising SLP
( Participate with the Speech-Language Pathologist in research projects, in-service training, and public relations programs.
VERIFICATION OF EMPLOYMENT AND SUPERVISION continued
I confirm that the above named employee shall NOT engage in the following:
← Administer diagnostic tests
← Interpret data into diagnostic statements or clinical management strategies or procedures
← Select or discharge cases
← Treat clients without following the individualized treatment plan
← Interpret clinical information including data or impressions relative to client performance
← Independent composition of clinical reports except for progress notes to be held in the client’s file
← Refer clients to other professionals or agencies
← Provide client or family counseling
← Develop or modify client's IEP/IFSP Clinical Report or Plan of Care in any way without the approval of the supervising SLP
← Disclose clinical or confidential information
← Sign any formal documents without the supervising SLP’s signature
I confirm that provision for supervision will be provided for the above named employee. Furthermore, the supervisor will meet the following minimal requirements:
← At least two years of experience working as a Speech-Language Pathologist
← Hold a New Mexico occupational license as a Speech-Language Pathologist
← Provide a minimum of 10% direct and 10% indirect contact time with the above named employee
The supervising Speech-Language Pathologist will be given a copy of this form.
I recognize that it is the employer’s responsibility to be sure that the supervising SLP is provided a work schedule that will allow for the necessary supervision of the employee listed above.
School District or Business: __________________________________________________________
PART III - SIGNATURES
Signature of Supervisor:
Title: Date:
Signature of Employer:
Title: Date:
Signature of Applicant:
Title: Date:
VERIFICATION OF EDUCATION
FOR TEMPORARY PARAPROFESSIONAL LICENSE
AS AN APPRENTICE IN SPEECH-LANGUAGE
To be completed by program director in the college in which the applicant is currently enrolled.
Name of Applicant: ________________________________________ Date: ________________
Address: ______________________________________________________________________
City: ________________________ State: _____________ Zip: _________ Phone:
I _____________________________ am requesting the release of the following information:
Applicant Name
Check one of the following:
( Enrolled in a Master’s Degree program in Speech-Language Pathology or Communication Disorders and completes a minimum of 9 semester hours per year of graduate courses in Communication Disorders.
(Specify university and attach copy of degree plan)
OR
( Enrolled in and completes 9 semester hours of graduate courses per year with at least 3 hours in Communication Disorders, 6 hours may be taken in a related field.
(Specify university)
Indicate dates nine (9) hours of coursework will be or have been completed:
Has applicant met the GPA requirement of 3.0? ( Yes ( No
Acceptance into a Master’s Degree program must take place within two years of initial license.
Program Director’s Name (Print)
Program Director’s Signature Date
JURISPRUDENCE EXAMINATION
1. The primary function of the Speech-Language Pathology, Audiology and Hearing Aid Dispensing Practices Board is to assure the safety and welfare of the public served.
T____ F____
2. Under Section 61-14B-22 – Penalties, any person who violates any provision of the Speech Language Pathology, Audiology and Hearing Aid Dispensing Act is guilty of a misdemeanor.
T____ F____
3. If not accepted into a Master’s degree program, in order to renew the license, a licensee must complete nine semester hours of graduate coursework in Communication Disorders per year.
T_____ F_____
4. An Apprentice must maintain a 3.5 GPA to be in compliance with the educational requirements.
T_____ F_____
5. An ASL (apprentice) license may not be renewed if the licensee has not been accepted into a Master's program within two years of initial licensure.
T_____ F_____
6. Timely renewal of licenses is the full and complete responsibility of the licensee.
T_____ F_____
7. Renewal of licenses must be postmarked no later than the expiration date (August 30) or a late fee will be assessed.
T____ F____
8. The role of the Apprentice in Speech-Language shall be determined in collaboration with the supervising Speech Language Pathologist (SLP) and the employer.
T_____ F_____
9. Licensees or applicants shall bear all costs of disciplinary proceedings unless they are excused by the Board from paying all or part of the fees or if they prevail at the hearing.
T____ F____
10. As required by federal law, final adverse disciplinary actions taken by the Board against applicants or licensees will be reported to the Federal Health Care Integrity and Protection Data Bank (or its successor data bank).
T_____ F_____
11. Apprentices in Speech Language (ASL’s) can administer diagnostic testing.
T_____ F_____
12. Direct supervision means on-site, in-view observation and guidance by a licensed professional in the applicant’s field present during therapy sessions with clients while an assigned activity is performed by support personnel.
T_____ F_____
13. All licensees must display their license in their primary location at their place of employment.
T_____ F_____
14. Temporary (ASL) licenses are terminal and may be renewed no more than five times total.
T_____ F_____
15. All licenses expire annually. What is the expiration date of your license for your specific field? ___________________
16. The Board has authority to impose penalties in disciplinary matters. List five forms of discipline that may be imposed by the Board.
1. ________________________________________________________________
2. ________________________________________________________________
3. ________________________________________________________________
4. ________________________________________________________________
5. ________________________________________________________________
17. The Board has adopted Part 9, Code of Ethics. What is the purpose of the Code of Ethics?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
18. In accordance with the provisions of the Uniform Licensing Act, the Board may take disciplinary action for violations of the Speech-Language Pathology, Audiology and Hearing Aid Dispensing Practices Act or the Board’s regulation. List five violations that may be grounds for disciplinary action.
1. __________________________________________________________________
2. __________________________________________________________________
3. __________________________________________________________________
4. __________________________________________________________________
5. __________________________________________________________________
19. The Rules list twelve (12) employment duties an ASL cannot provide. List five of the employment duties an ASL cannot provide.
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________
5. ___________________________________________________________________
20. Employment duties are limited. List three (3) employment duties an ASL may provide.
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
Signature: ___________________________________________ Date: ____________________
-----------------------
New Mexico Regulation and Licensing Department
BOARDS AND COMMISSIONS DIVISION
New Mexico Speech-Language Pathology, Audiology and Hearing Aid Dispensing Practices Board
PO Box 25101 ª% Santa Fe, New Mexico 87505
(505) 476-4640 ª% Fax (505) 476-4620 ª% rld.state.nm.us
▪ Santa Fe, New Mexico 87505
(505) 476-4640 ▪ Fax (505) 476-4620 ▪ rld.state.nm.us
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