Free 37911.FH11 - Indiana

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APPLICATION FOR LICENSE TO PRACTICE SPEECH-LANGUAGE PATHOLOGY OR AUDIOLOGY
State Form 37911 (R10 / 2-06)

Approved by State Board of Accounts, 2006 *Your Social Security number is being requested by this state agency in accordance with I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

SPEECH LANGUAGE PATHOLOGY AUDIOLOGY BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2064 E-mail: [email protected]

APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER LICENSE ISSUANCE DATE (month, day, year) DO NOT WRITE ABOVE THIS LINE - FOR OFFICE USE ONLY
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Address (number and street or rural route) City Date of birth (month, day, year) Telephone number (daytime) Place of birth (city and state or country) E-mail address State ZIP code Social Security number*

APPLICANT Attach one (1) passport-quality photograph taken not earlier than one (1) year prior to the date of application.

(

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APPLYING FOR LICENSURE AS: (Please check one)

Speech-Language Pathologist

Audiologist
DATE OF GRADUATION (month, day, year)

MASTERS DEGREE GRANTED BY NAME OF SCHOOL LOCATION OF SCHOOL

EXAMINATION RECORD EXAMINATION TAKEN ETS - PRAXIS Series AMERICAN SPEECH-LANGUAGE HEARING ASSOCIATION (ASHA) CERTIFICATION Do you hold an ASHA certification?
Certification number Date of issuance (month, day, year)

DATE OF MOST RECENT EXAMINATION (month, day, year)

WHERE TAKEN

HOW MANY TIMES HAVE YOU SAT FOR THIS EXAMINATION

Yes
Date of expiration (month, day, year)

No

PRE-PROFESSIONAL EDUCATION NAME OF SCHOOL LOCATION OF SCHOOL DATES ATTENDED (month, day, year) DEGREE GRANTED

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DIRECT SUPERVISED CLINICAL EXPERIENCE
Was your supervised clinical experience completed in a:

Educational Institution

Clinical Program Associated with the Institution

How many hours of supervised, direct clinical experience did you receive?

CLINICAL EXPERIENCE COMPLETED: PROGRAM / INSTITUTION SUPERVISOR LOCATION START DATE (month, day, year) COMPLETION HOURS DATE COMPLETED (month, day, year)

COMPLETION OF CLINICAL FELLOWSHIP (CFY)
Do you hold or have you held a CFY registration in the State of Indiana?

Yes
Registration number Was your clinical fellowship completed in: Date of issuance (month, day, year)

No
Date of expiration (month, day, year)

Nine (9) consecutive months (30 hours per week) Twelve (12) consecutive months (25 to 29 hours per week) SUPERVISOR LOCATION

Fifteen (15) consecutive months (20 to 24 hours per week) Eighteen (18) consecutive months (15 to 19 hours per week) START DATE (month, day, year) COMPLETION DATE (month, day, year) HOURS WORKED PER WEEK

STATES LICENSED LICENSE TYPE STATE NUMBER DATE ISSUED (month, day, year) EXPIRATION DATE (month, day, year) STATUS

LIST ALL PLACES YOU LIVED SINCE GRADUATION GENERAL LOCATION DATES (month, day, year)

LIST ALL PLACES OF EMPLOYMENT SINCE GRADUATION FROM YOUR MASTERS DEGREE PROGRAM DATES OF EMPLOYMENT NAME AND ADDRESS OF EMPLOYER RESPONSIBILITIES (month, day, year)

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If your answer is Yes to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. If malpractice, provide name(s) of plaintiff(s). Letters from attorneys or insurance companies are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a license issued pursuant to this application. 1. Have you ever previously filed an application in the State of Indiana? 2. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit you hold or have held? 3. Have you ever been denied a license, certificate, registration or permit to practice speech-language pathology or audiology or any regulated health occupation in any state (including Indiana) or country? 4. Are you now being, or have you ever been, treated for drug or alcohol abuse? 5. Have you ever been convicted of, plead guilty, or nolo contendre to: A. A violation of any Federal, State, or local law relating to the use, manufacturing, distribution or dispensing of controlled substances or drug addiction? B. Any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines.) 6. Have you ever been denied staff membership or privileges in any hospital or health care facility or had such membership or privileges revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations? 7. Have you ever been admonished, censured, reprimanded or requested to withdraw, resign or retire from any hospital or health care facility in which you have trained, held staff membership or privileges or acted as a consultant? 8. Have you ever had a malpractice judgment against you or settled any malpractice action? APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date signed (month, day, year)

YES YES YES YES YES YES YES YES YES

NO NO NO NO NO NO NO NO NO

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, corporation, association, organization or institution to release to the Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of its authorized representatives in connection with processing my application for a license to practice speech-language pathology or audiology. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm, that I have read the above statements and agree to same.
Signature of applicant Date signed (month, day, year)

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VERIFICATION OF SPEECH-LANGUAGE PATHOLOGIST OR AUDIOLOGIST LICENSURE
INSTRUCTIONS: Type or print the top portion of the verification and send a copy to each state where you hold or have held a license. Request each state to complete and send directly to:

Professional Licensing Agency 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2064 Email: [email protected]
Name (last, first, middle, maiden) Address (number and street, rural route) City Date of birth (month, day, year) Telephone number (daytime) State E-mail address ZIP code Social Security number *

(
I hereby authorize the State of Agency with the information below.
Signature

)
to furnish the Professional Licensing

Date signed (month, day, year)

TO BE COMPLETED BY THE STATE BOARD
License number License issued based upon: Date of issuance (month, day, year) Date of expiration (month, day, year)

Examination

Endorsement

Certificate of Clinical Competence From ASHA (CCCs)

Other _________________________________
Type of examination: Date of examination(s) (month, day, year)

ETS-PRAXIS Series State Constructed Examination (Attach subjects, scores and average) Has the license been subject to any disciplinary action? (Please attach certified copies of any disciplinary action taken by your board.) FORM COMPLETED BY:
Name Title State Board Date (month, day, year)

Yes

No

PLEASE AFFIX BOARD SEAL

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