Memorandum - New Jersey Division of Consumer …

1 New Jersey Office of the Attorney GeneralDivision of Consumer AffairsAudiology and Speech-Language PathologyAdvisory Committee124 Halsey Street, 6 Floor, PO Box 45002, Newark, NJ 07101thMemorandumTO:Applicants for Licensure in Audiologyand/or Speech-Language PathologyFROM:Dorcas K. O Neal, Executive DirectorRE:Useful Information for New Jersey Licensure Applicants ALERT JURISPRUDENCE ORIENTATION FOR AUDIOLOGISTS AND SPEECH LANGUAGEPATHOLOGISTSThe New Jersey Legislature finds and declares that the practice of audiology and speechlanguage pathology needs to be regulated for the protection of the health, safety andwelfare of the citizens of this State. In order to raise awareness of current New Jerseystatutes and regulations applicable to the practice of audiology and speech languagepathology, it is now required that all new applicants for licensure (13 (c);applicants who are licensed in other states who wish to become licensed in New Jersey (13 (d).))

2 Individuals apply for temporary licenses (13 (c) and currentlicensees who are renewing their license as part of their biennial license renewal andreinstatement (13 (i), complete an online Jurisprudence note that 1) under the medical conditions section of the application (questionnumber 7), there are instances when the answer NOT APPLICABLE may apply, and 2) itis a very good idea to make sure you read the entire application before filling it follow the instructions carefully and remember that full compliance is necessary beforeyou will be issued a license and can begin assist you, we have listed some common pitfalls which delay processing: For your convenience, please be advised that our Reporting Code Number foryour PRAXIS score is R7668. Use of this number when requesting transmissionwill facilitate processing.

3 When applying for a Temporary License, make certain that your SupervisionPlan meets the requirements of 13 When practicing under a Temporary License during your Clinical Internship,REMEMBER you must complete your Clinical Internship in the time indicatedon your Supervision Plan. For those practicing full-time this is 9 months, forthose practicing part time it may be up to 18 months. PLEASE NOTE THATYOUR TEMPORARY LICENSE ENDS WHEN YOU COMPLETE YOUR CLINICALINTERNSHIP. You must obtain your permanent license in order to continue toprovide services. The temporary license cannot be renewed. Any change in supervision, including supervisor, location, or interruption ofsupervision must be promptly reported to the Committee s TO COMPLETING YOUR CLINICAL INTERNSHIP, BE SURE PROPERNOTIFICATION IS MADE TO THIS OFFICE 2 MONTHS BEFORE YOURENDING will allow ample time for processing so there is no lapse of your licensingbetween the time your temporary license expires and your permanent license MAY NOT PRACTICE UNDER A TEMPORARY LICENSE BEYOND THEDATE INDICATED ON YOUR SUPERVISION not confuse the New Jersey Audiology and Speech-Language PathologyAdvisory Committee with ASHA.

4 The fact that ASHA is in receipt of yourrecords does not satisfy your obligation to the State of New )TranscriptsYou are required to submit an original transcript bearing the raised seal of the collegeor university where you earned your graduate degree. B)Jurisprudence OrientationYou must go to , to complete the JurisprudenceOrientation that is now required. PUT THE ADDRESS IN YOUR WEB you have questions relating to the application procedure, you may call (973) NoteOnce your application process is completed, your temporary license will be processed. LICENSE NUMBERS WILL NOT BE GIVEN OVER THE PHONE. PLEASE DO NOT CALL THEOFFICE TO OBTAIN YOUR TEMPORARY LICENSE Jersey Office of the Attorney GeneralDivision of Consumer AffairsAudiology and Speech-Language Pathology Advisory CommitteePO Box 45002 Newark, New Jersey 07101 Checklist for Temporary License - Clinical Internship Important: Do not send in partially completed applications, they will be returned.

5 To facilitatethe processing of your application, without delay, please be sure you have complied with thischecklist and application is complete. All questions must be (2) passport size photos are included. The photos should be of your head andshoulders only and be (2" x 2"), taken within the past six transcripts of grades from the college or university granting you your graduatedegree(s). (School seal must be affixed.) 9 Transcripts of grades in Audiology and/or Speech-Language Pathology for the PraxisExamination (Administered by the Educational Testing Service). THIS MUST BESUBMITTED PRIOR TO PERMANENT and Authorization Form for a Criminal History Background supervision plan (For temporary license to complete a Clinical Internshiponly)9 Change of name documentation, when the Jurisprudence Orientation at PUTTHE ADDRESS IN YOUR WEB : Payable to the State of New Jersey9 Application fee and temporary fee - $ return this completed checklist with your applicationNew Jersey Office of the Attorney GeneralDivision of Consumer AffairsAudiology and Speech-Language Pathology Advisory Committee124 Halsey Street, 6th Floor, Box 45002 Newark, New Jersey 07101(973) 504-6390 Temporary License Application - Clinical InternshipCheck one.

6 Audiology Speech-Language Pathology Audiology Speech-Language Pathology Date: _____Please enclose a nonrefundable application filing fee of $ and a temporary license fee of $ (total fee $ ) in the form of a check or money order made out to the State of New Jersey . (Applicants should understand that if the fees are paid with a personal check, and the check is returned by the bank due to insufficient funds, the next step in the licensure or certification process will be delayed until the fees are paid.) The Committee maintains, as part of its responsibilities, a record of your home address, business address and mailing address. You may choose which of these addresses will be considered as your address of record. If you do not indicate (by putting a check in the appropriate box) which address should be used as your address of record, your mailing address will be considered to be your address of record.

7 A post office box may be used as your address of record, but only if you provide another address which includes a street, city, state and ZIP that you provide on this application (including your address of record) may be subject to public disclosure as required by the Open Public Records Act (OPRA).Please print clearly. You must answer all of the questions on this Information Date of birth: _____ Month Day Year Place of birth: _____ City State Name Mrs. _____( _____) Ms. Last name First name Middle initial Maiden name2. Address Home: _____ Street or Box City State ZIP code County _____ _____ Telephone number (include area code) E-mail address Business: _____ Name of company Telephone number (include area code) _____ Street City State ZIP code County Mailing: _____ Street or Box City State ZIP code CountyPhoto #1 Photo #2 Attach two clear, full-face pass-port-style photographs (2 x 2 ) of your head and shoulders, taken within the past six months.

8 Two photographs are required with each not use staples to attach the Social Security Number You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of licensure or certification. *Social Security Number: _____-_____- _____ *Pursuant to 54:50-24 et seq. of the New Jersey taxation law, 2 of the New Jersey Child Support Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 , and , the Board or Committee is required to obtain your Social Security number. Pursuant to these authorities, the Board or Committee is also obligated to provide your Social Security number to: a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing compliance with State tax law and updating and correcting tax records; b.

9 The Probation Division or any other agency responsible for child support enforcement, upon request; and c. the National Practitioner Data Bank and the Data Bank, when reporting adverse actions relating to health care Citizenship / Immigration Status Federal law limits the issuance or renewal of professional or occupational licenses or certificates to citizens or qualified aliens. To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not a citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the office of Citizenship and Immigration Services (USCIS). citizen Alien lawfully admitted for permanent residence in Other immigration status Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the USCIS at: Student Loan Are you in default in regard to any student loan obligation(s)?

10 Yes No If Yes, you must obtain documentary evidence that you have reached an arrangement with the bank or with the entity that issued your student loan, for the eventual repayment of the loan. You will not be able to obtain a license or certificate unless you provide the required documents concerning there plan for payment of your student Child Support Please certify, under penalty of perjury, the following: a. Do you currently have a child-support obligation? Yes No (1) If Yes, are you in arrears in payment of said obligation? Yes No (2) If Yes, does the arrearage match or exceed the total amount payable for the past six months? Yes No b. Have you failed to provide any court-ordered health insurance coverage during the past six months?