Ariz. Admin. Code § R9-16-204 - Initial Application for a Speech-language Pathologist

A. An applicant for a temporary speech-language pathologist license shall submit to the Department:

1. An application in a format provided by the Department that contains:

a. The applicant's name, home address, telephone number, and e-mail address;

b. The applicant's Social Security number, as required under A.R.S. §§ 25-320 and 25-502 ;

c. If applicable, the applicant's business address and telephone number;

d. If applicable, the name of the applicant's employer, including the employer's business address and telephone number;

e. Whether the applicant has ever been convicted of a felony or a misdemeanor involving moral turpitude in this or another state;

f. If the applicant has been convicted of a felony or a misdemeanor involving moral turpitude:

i. The date of the conviction,

ii. The state or jurisdiction of the conviction,

iii. An explanation of the crime of which the applicant was convicted, and

iv. The disposition of the case;

g. Whether the applicant is or has been licensed as a speech-language pathologist in another state or country;

h. Whether the applicant has had a license revoked or suspended by any state within the previous two years;

i. Whether the applicant is currently ineligible for licensing in any state because of a license revocation or suspension;

j. Whether any disciplinary action, consent order, or settlement agreement is pending or has been imposed by any state or country upon the applicant's speech-language pathologist license;

k. Whether the applicant agrees to allow the Department to submit supplemental requests for information under R9-16-209 ;

l. An attestation that the information submitted is true and accurate; and

m. The applicant's signature and date of signature;

2. If applicable, a list of all states and countries in which the applicant is or has been licensed as a speech-language pathologist;

3. If a license for the applicant has been revoked or suspended by any state within the previous two years, documentation that includes:

a. The date of the revocation or suspension,

b. The state or jurisdiction of the revocation or suspension, and

c. An explanation of the revocation or suspension;

4. If the applicant is currently ineligible for licensing in any state because of a license revocation or suspension, documentation that includes:

a. The date of the ineligibility for licensing,

b. The state or jurisdiction of the ineligibility for licensing, and

c. An explanation of the ineligibility for licensing;

5. If the applicant has been disciplined by any state, territory or district of this country for an act related to the applicant's audiologist license that is grounds for disciplinary action under Title 37, Chapter 17, documentation that includes:

a. The date of the disciplinary action;

b. The state or jurisdiction of the disciplinary action;

c. An explanation of the disciplinary action; and

d. Any other applicable documents, including a legal order or settlement agreement;

6. A copy of the applicant's:

a. U.S. passport, current or expired;

b. Birth certificate;

c. Naturalization documents; or

d. Documentation of legal resident alien status;

7. Documentation of the applicant's:

a. Official transcript issued to the applicant by an accredited college or university after the applicant's completion of a master's degree consistent with the standards of this state's universities, as required in A.R.S. § 36-1940.01(A)(2)(a) ; and

b. Completion of a clinical practicum, as required in A.R.S. § 36-1940.01(A)(2)(b) ;

8. A copy of the applicant's clinical fellowship agreement that includes:

a. The applicant's name, home address, and telephone number;

b. The clinical fellowship supervisor's name, business address, telephone number, and Arizona audiology or speech-language pathology license number;

c. The name and address where the clinical fellowship will take place;

d. A statement by the clinical fellowship supervisor agreeing to comply with R9-16-210 ; and

e. The signatures of the applicant and the clinical fellowship supervisor;

9. Documentation of the applicant's completion of the ETSNESLP as required in A.R.S. § 36-1940.01(A)(3) ; and

10. A nonrefundable $100 application fee.

B. A temporary license issued is effective for 12 months from the date of issuance.

C. A temporary license may be renewed only once.

D. An applicant issued a temporary speech-language pathologist license shall:

1. Practice under the supervision of a licensed speech-language pathologist, and

2. Not practice under the supervision of individual who has a temporary speech-language pathologist license.

E. The Department shall review an application packet for a temporary speech-language pathologist license according to R9-16-209 and Table 2.1.

In addition to complying with R9-16-202(A), an applicant for initial licensure as a speech-language pathologist shall submit to the Department the following:

1. A transcript or equivalent documentation issued to the applicant by an accredited college or university after the applicant's completion of a master's degree consistent with the standards of this state's universities, as required in A.R.S. § 36-1940.01(A)(2)(a) or documentation of current CCC;

2. Completion of a clinical practicum, as required in A.R.S. § 36-1940.01(A)(2)(b) or documentation of current CCC;

3. Documentation of the applicant's completion of the ETSNESLP as required in A.R.S. § 36-1940.01(A)(3) or documentation of current CCC; and

4. Documentation of the completion of clinical fellowship or documentation of current CCC.

Notes

Ariz. Admin. Code § R9-16-204

Former Section R9-16-204 repealed, new Section R9-16-204 adopted effective January 23, 1978 (Supp. 78-1). Repealed effective March 14, 1994 (Supp. 94-1). Adopted by final rulemaking at 5 A.A.R. 4359, effective October 28, 1999 (Supp. 99-4). Amended by final rulemaking at 10 A.A.R. 2063, effective July 3, 2004 (Supp. 04-2). New Section made by exempt rulemaking at 20 A.A.R. 1998, effective 7/1/2014. Adopted by final expedited rulemaking at 26 A.A.R. 816, effective 4/8/2020.