SPEECH-LANGUAGE PATHOLOGY          ASSISTANT LICENSE

Forms:

Checklist

Speech Assistant Application

Clinical Academic Requirement Form 

Letters of Agreement

First 90 day Supervision Log

SLPA weekly Supervision Log

SPEECH-LANGUAGE PATHOLOGY LICENSE

Forms:  

Checklist 

Licensure Application 

CLINICAL FELLOW LICENSE 

Forms:

Checklist 

CF Application

Letters of Agreement

CF Plan

AUDIOLOGY LICENSE 

Forms:

Checklist 

Licensure Application

AUDIOLOGY ASSISTANT

AUTHORIZATION

Forms:

Checklist

Application 

Letters of Agreement 

OBESPA MAIL-IN

RENEWAL AND DEACTIVATION FORMS

 2021 Renewal Form

2021 Deactivation Form

GENERAL FORMS

• Academic Preparation and Practicum Verification Form
• Complaint Form
• Continuing Education Form and List of Approved CE Activities
• Non-Accredited Degree Program Practicum Form
• Non-Accredited Degree Program Preparation Form
• Reactivation Form
• Report of Clinical Fellowship
• Required Reference Letter
• Verification of Citizenship Affidavit
• Verifying Qualified Alien Status Affidavit