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PROCEDURES FOR REGISTRATIONSpeech Pathology Clinical Fellowship Year (CFY) orAudiology Clinical Extern (ACE)All supervising licensees must register any and all Clinical Fellows or Clinical Externs working under their supervisionwith the Board on a registration form. Registration must be made by the supervising licensee before or within ten (10) daysof retaining each Clinical Fellow.An applicant for registration as a Clinical Fellow or Clinical Extern shall successfully complete a minimum of fourhundred (400) clock hours of supervised clinical experience (practicum) with individuals having a variety ofcommunication disorders, as required by ASHA. The experience shall have been obtained through an accredited collegeor university which is recognized by ASHA. The applicant shall cause the Department Chair or other program head toprovide directly to the Board’s Administrative Office a letter attesting to the standards of the Practicum and the applicant’ssuccessful completion, and the number of clinical hours achieved.CFY: An applicant for registration as a Clinical Fellow (CFY) shall cause a graduate transcript to be submitted directlyfrom the educational institution to the Board’s Administrative Office. The transcript must show that graduation with atleast a Master’s or Doctorate level degree has been completed and must carry the official seal of the institution.ACE: An applicant for registration as an Audiology Clinical Extern (ACE) shall cause a letter to be submitted directlyfrom the educational institution to the Board’s Administrative Office. The letter must show that the applicant hassuccessfully completed sufficient academic course work to engage in outside supervised clinical practicePERIOD OF EFFECTIVENESS CFY:Clinical fellowships are effective for a period of no less than nine (9) months and no more than one (1) year.The clinical fellowship’s period of effectiveness for applicants for licensure who are awaiting national certification andsubsequent Board review of their application for licensure may be extended for a period not to exceed three (3) additionalmonths. Such extension will cease to be effective if national certification or Board licensure is denied. At all times whileawaiting national certification results and until licensure is received, clinical fellows shall practice only under supervisionas set forth in rule 1370-01-.10(1).Application for licensure or a three (3) month extension of the clinical fellowship should be made thirty (30) days beforethe expiration of the clinical fellowship registration.Supervising licensees may only supervise three (3) Registered Clinical Fellows concurrently or two (2) Registered SpeechAssistants concurrently. They cannot supervise more than a total of three concurrently.PERIOD OF EFFECTIVENESS ACE:Audiology Externships are effective for a period of no less than fifteen (15) continuous months.The Audiology Externship’s period of effectiveness for applicants for licensure who are awaiting national certification andsubsequent Board review of their application for licensure may be extended for a period not to exceed four (4) additionalmonths. Such extension will cease to be effective if national certification or Board licensure is denied. At all times whileawaiting national certification results and until licensure is received, clinical fellows shall practice only under supervisionas set forth in this rule.Application for licensure or a four (4) month extension of their Audiology Externship should be made thirty (30) daysbefore the expiration of their Audiology Externship registration.Supervising licensees may only supervise two (2) Registered Audiology Externs concurrently.BF/G4025292/CDS (Rev. 05/20)Page 1RDA 10137

UNDERSTANDING THE APPLICATION PROCESSIf an address change occurs at any time, you MUST notify the Board office in writing immediately.1.All documents required to be submitted must be mailed directly to:Board of Communication Disorders and Sciences665 Mainstream DrNashville, TN 37243We cannot accept faxed or emailed applications.2.Please allow fourteen (14) working days for information mailed to our office to be received and placedin your file. The Board asks that you please give the Board office every consideration in thismatter.3.If necessary documentation has not been received when your application has been received by theBoard office, an initial deficiency letter will be sent to you by mail or email.4.All applicants must complete the Declaration of Citizenship form found at and have it achments/PH-4183.pdf5.All applicants must complete a criminal background check. The instructions can be found criminal-background-check.html6.Absent any complicating factors, the average application processing time is six weeks. Once theapplication is completed, your file will be promptly reviewed and an initial certification determinationmade. You will be promptly notified by letter of the initial determination.7.Applications that are deficient sixty (60) days after receipt of the initial deficiency letter will be closed.Thank you for your cooperation. We will make every effort to expedite your application in an efficient manner.In order to comply with federal statutes, the Board of Communications Disorders and Sciences is obligated to inform each applicantor licensee from whom it requests a social security number that disclosing such number is mandatory in order for this Board tocomply with the requirements of the federal Healthcare Integrity and Protection Data Bank and/or the National Practitioner DataBank. If the Board is required to make a report about one of its applicants or licensee to either or both of these data banks, it mustreport that individual’s social security number. This application will not be complete if the social security number is omitted. Thenumber will be used for identification purposes and for such purposes as are allowed by the state and federal law.IMPORTANT: You must have a registration from the Board in your possession before you may lawfully practicein a Speech Pathology Clinical Fellowship or Audiology Clinical Externship.BF/G4025292/CDS (Rev. 05/20)Page 2RDA 10137

STATE OF TENNESSEEDEPARTMENT OF HEALTHOFFICE OF HEALTH LICENSURE AND REGULATION665 Mainstream DrNashville, TN 37243http://tn.gov/health/topic/CDS-boardBOARD OF COMMUNICATION DISORDERS AND SCIENCES(615) 741-5735 or 1-800-778-4123APPLICATION for CLINICAL FELLOWSHIP YEAR (CFY) or AUDIOLOGY CLINICAL EXTERNSHIP (ACE)CFYACEName:LastFirstMiddleMaidenCurrent Home Mailing Address:Current Practice Name and Address: **If you have no practice address, notify the Board of your practice address within 30 days of obtaining a practice address. If you havemultiple practice address, please attach an additional page listing all practice addresses.Phone (Home):U. S. CITIZEN: YesNo(Work):Entitled to Live and Work in the U.S.: Yes NoAll applicants must complete the Declaration of Citizenship form and have it notarized.Social Security Number: - -Date of Birth:E-Mail:Do you wish to receive notifications, including renewal notification, from Department of Health via email? Please note, by opting in, all correspondencefrom the Department of Health will be delivered to the email address on file for you. You will no longer receive physical mail from our office. YesNoGender: FemaleMaleRace:Are you a member of the U.S. armed forces who has, within the preceding 180 days, retired from the armed forces, received anydischarge other than a dishonorable discharge from the armed forces, or been released from active duty to a reserve component of thearmed forces? (If yes, please provide proof of status.) Yes NoAre you the spouse of a member of the armed forces who has been transferred by the military to Tennessee or who has, within thepreceding 180 days, retired from the armed forces, received a discharge other than a dishonorable discharge from the armed forces orbeen released from active duty to a reserve component? (If yes, please provide proof of same.) Yes NoHave you ever been known by any other names besides what is listed above? Yes NoIf yes, please state in full every other name by which you have been known, the reason therefore, and inclusive dates so known:BF/G4025292/CDS (Rev. 05/20)Page 3RDA 10137

EDUCATIONAL INFORMATIONPlease provide the following information for all educational institutions you have attended beyond high school. Use theback of this page if you need additional space.From: To:Mo/YrMo/YrEducational InstitutionDegree AwardedFrom: To:Mo/YrMo/YrEducational InstitutionDegree AwardedFrom: To:Mo/YrMo/YrEducational InstitutionDegree AwardedFrom: To:Mo/YrMo/YrEducational InstitutionDegree AwardedMasters Degree Awarded By: Degree Date:Doctoral Degree University: Degree Date (or anticipated)Practice Site for CFY/ACE:Practice Address:CFY/ACE Supervisor:(Supervisor must be 2 years post-CFY/ACE)TN License Number:(If ASHA certified only, must include copy of ASHA card)LICENSURE INFORMATIONHave you ever previously applied for a speech pathology or audiology license in Tennessee?YesNoIf you have an NPI number, please provideYESAre you or have you ever been licensed in this profession in another state?Are you or have you ever been licensed in any other profession in Tennessee or another state?BF/G4025292/CDS (Rev. 05/20)Page 4RDA 10137NO

List below ALL STATES, COUNTRIES, OR PROVINCES IN WHICH YOU HAVE EVER BEEN OR ARECURRENTLY LICENSED, PERMITTED, OR CERTIFIED. Additional pages may be added if necessary. Request thatverification of licensure be submitted directly to the Board’s Office from each state.STATEPROFESSIONLICENSE NUMBERCURRENT STATUSEMPLOYMENT STATUSAre you currently employed? Yes NoIf yes, give name and address of primary employer:Do you engage in private practice? Yes No (If yes, give location):Have you ever held a job in a healthcare profession?Yes: No:Please complete your entire healthcare employment history starting with the most current position first. Use the back ofthis page, if you need additional space. Dates of employment must be included.Company/Employer:BF/G4025292/CDS (Rev. 05/20)Name ofSupervisorAddress:(City, andState)Page 5Position:Duties:DatesFrom:To:Mo./Yr. Mo./Yr.RDA 10137

COMPETENCY INFORMATIONPLEASE ANSWER THE FOLLOWING QUESTIONS. If you answer “yes” to any of the questions in this part, you mustsupplement your affirmative response with a thorough explanation on a separate page. IN SUPPORT OF YOUR EXPLANATION,THE FINAL DOCUMENTS OR ORDERS FROM THE ISSUING STATES, COURTS, AND/OR AGENCIES MUST BESUBMITTED ALONG WITH THIS APPLICATION. Additional information may be requested and/or required before a licensuredecision may be made. For the purposes of these questions, the following phrases or words have the following meanings:1. “Ability to practice your profession" is to be construed to include all of the following:a. The cognitive capacity to make appropriate clinical diagnoses, exercise reasoned medical judgments, to learn, and keepabreast of medical developments;b. The ability to communicate those judgments and medical information to patients and other health care providers, with orwithout the use of aids or devices, such as voice amplifiers; andc. The physical capability to perform professional tasks and procedures required of your profession, with or without the use ofaids or devices, such as corrective lenses or hearing aids.2. “Medical Condition" includes physiological, mental or psychological conditions including, but not limited to: orthopedic, visual,speech and/or hearing impairments, emotional or mental illness, specific learning disabilities, drug addiction, and alcoholism.3. "Minor Traffic Offense” generally means moving and non-moving violations punishable by fines only and does not includeoffenses such as driving under the influence or while intoxicated or reckless driving.4. “Chemical substances" is to be construed to include alcohol, drugs, or medications, including those taken pursuant to a validprescription for legitimate medical purposes and in accordance with the prescriber's direction, as well as those used illegally.5. “Currently" does not mean on the day of or even in the weeks or months preceding the completion of this application. Rather itmeans recently enough so that the use of drugs or alcohol may have an ongoing impact on one's functioning as a licensee or withinthe past two (2) years.6. “Illegal use of illicit or controlled substances" means the use of substances obtained illegally (e.g., heroin or cocaine) as wellas the use of controlled substances that are not obtained pursuant to a valid prescription or not taken in accordance with the directionsof a licensed health care practitioner.QUESTIONS:1.2.Please respond to ALL questions. If you answer "YES" to any question, please attach a written explanation.YESNODo you currently have any physical or psychological limitations orimpairments caused by an existing medical condition which are reducedor ameliorated by ongoing treatment or monitoring, or the field of practice,the setting or the manner in which you have chosen to practice?Do you currently use any chemical substances which in any way impair orlimit your ability to practice your profession with reasonable skill and safety?If so, please list:[If you receive such ongoing treatment or participate in such a monitoring program, the Council will make an individual assessmentof the nature, the severity and the duration of the risks associated with an ongoing medical conditions so as to determine whetheran unrestricted license should be issued, whether conditions should be imposed, or whether you are ineligible for licensure.]YESBF/G4025292/CDS (Rev. 05/20)Page 6NORDA 10137

3.At any time within the past two years, have you engaged in the illegal use ofillicit or controlled substances?Are you currently participating in a supervised rehabilitation program orprofessional assistance program that monitors you in order to assure that youare not engaged in the illegal use of illicit or controlled substances?Have you ever been diagnosed as having or have you ever been treated forpedophilia, exhibitionism, voyeurism or other diagnosis of a predatory nature?Have you ever held or applied for a license, privilege, registration or certificate topractice as a hearing aid dispenser in any state, country, or province, that has beenor was ever denied, reprimanded, suspended, restricted, revoked, otherwisedisciplined, curtailed, or voluntarily surrendered under threat of investigation ordisciplinary action?Have you ever had staff privileges at any hospital or health care facility that wereever revoked, suspended, curtailed, restricted, limited, otherwise disciplined,or voluntarily surrendered under threat of restriction or disciplinary action?Have you ever applied for or held a state or federal controlled substance certificatethat was ever denied, revoked, suspended, restricted, voluntarily surrendered orotherwise disciplined or surrendered under threat of restriction or disciplinaryaction?Have you ever been convicted (including a nolo contendere plea or guilty plea) ofa felony or misdemeanor (other than a minor traffic offense) whether or notsentence was imposed or suspended?10.Have you ever been rejected or censured by a professional association or society?11.In relation to the performance of your professional services in any profession:4.5.6.7.8.9.12.13.a.Have you ever had a final judgment rendered against you;b.Have you ever entered into any settlement of any legal action; orc.Are there any legal actions pending against you or to which you are a party?Have you ever held a license, registration, privilege or certificate in any professionthat has ever been reprimanded, suspended, restricted, revoked, otherwisedisciplined, curtailed, or voluntarily surrendered under threat of investigation ordisciplinary action in any jurisdiction?My name has been placed on the registry of persons who have abused, neglected ormisappropriated the property of vulnerable individuals (Tennessee abuse registry oran abuse registry in another state)BF/G4025292/CDS (Rev. 05/20)Page 7RDA 10137

AFFIDAVIT AND RELEASEI, , of , being duly(Name)(City)(State)sworn and identified as the person referred to in this application, attest to the truth of each statement made in saidapplication. I further attest that I have read and understand the law and the rules and regulations regarding the practice ofmy profession, which are posted on the Board’s internet site and/or were provided to me by the Board office, and agree toabide by them in the practice of Speech Pathology or Audiology in the State of Tennessee.I HEREBY:SIGNIFY my willingness to appear to answer such questions as the Board may find necessary which may include a fullBoard interview.RELEASE to the Board, its staff, and their representatives, any and all documentation necessary now and in the future toestablish my physical and mental capabilities to safely practice Speech Pathology/Audiology.AUTHORIZE the Board, its staff, and their representatives to consult with my prior and current associates and others whomay have information bearing on my professional competence, character, health status, ethical qualifications, ability towork cooperatively with others and other qualifications;RELEASE from liability the Board, its staff, and all their representatives and any and all organizations which provideinformation for their acts performed and statements made in good faith and without malice concerning my competence,ethics, character and/or other qualifications for certification.ACKNOWLEDGE that I, as an applicant for certification, have the burden of producing adequate information for a properevaluation of my professional, ethical and other qualifications and for resolving any doubts about such qualifications.AUTHORIZE release, use and disclosure of otherwise HIPAA protected health information to the limited extentnecessary for my application to receive full consideration up to and including discussion in a public forum should thatbecome necessary.THIS CERTIFIES THAT THE INFORMATION SUBMITTED BY ME IN THIS APPLICATION IS TRUE ANDCOMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF.SIGNATUREBF/G4025292/CDS (Rev. 05/20)Page 8DATERDA 10137

CFY/ACE SUPERVISOR REGISTRATION FORMCFY/ACE Registrant Name:LastFirstMiddleMaidenName of Supervisor:LastFirstMiddleMaidenTN License Number of SupervisorASHA Certification NumberPractice Name:Practice Address:Phone:Email address:I, have agreed to provide required andappropriate supervision to , registrant for CFY/ACE, atfor the period of(location)(city and state)(Month/Day/Year)Full Timeto(Month/Day/Year)Part TimeSupervisor Signature: Date:Please return completed form to:BF/G4025292/CDS (Rev. 05/20)Tennessee Board of Communications Disorders and Sciences665 Mainstream DrNashville, TN 37243Page 9RDA 10137

decision may be made. For the purposes of these questions, the following phrases or words have the following meanings: 1. "Ability to practice your profession" is to be construed to include all of the following: a. The cognitive capacity to make appropriate clinical diagnoses, exercise reasoned medical judgments, to learn, and keep