Application For Speech-Language Pathology And/or Audiology License
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2KANSAS DEPARTMENT FOR AGING & DISABILITY SERVICES
Health Occupations Credentialing
APPLICATION FOR
SPEECH-LANGUAGE PATHOLOGY AND/OR AUDIOLOGY LICENSE
TYPE OF LICENSE
Circle type of license.
Temporary: $65.00
Speech-Language Pathology
Full: $135.00
Audiology
Reciprocal: $135.00
See attached fee schedule. Fees are pro-rated for partial year license. Enclose non-refundable fee payable to “KDADS”.
Fees can be charged to Visa or Master Card. Charge authorization form must be completed and returned to utilize this option.
APPLICANT INFORMATION
Name:
Last
First
MI
Other
Address:
Phone: Work( ____ ) ______________ Home (___)____________ Birthdate: _____/_____/_____ SSN ______________
(Attach a copy of your Social Security Card or document bearing your name and Social Security Number.)
EDUCATION—List
College/University
Degree
Date Conferred
1.
_______________
____________
2.
_______________
____________
3.
_______________
____________
4.
_______________
____________
●Transcripts showing award of a Master’s Degree in Speech-Language Pathology and/or Audiology must be
sent by the college/university directly to Health Occupations Credentialing.
●The college/university must be regionally accredited by the United States Department of Education and with
American Speech-Language Hearing Association approved program. If you hold a degree or completed course
work from a non-accredited institution, you must complete Supplement A. (request from the department)
●Degrees or transcripts received from schools outside the United States or its territories must be translated
and/or evaluated by a validating agency.
CLINICAL PRACTICUM
TEMPORARY LICENSE
Single License: Submit documentation on institutional letterhead signed by the college/university program or clinical
director verifying completion of 400 clinical practicum hours, of which at least 325 hours were completed
at graduate level.
Dual License: Submit documentation on institutional letterhead signed by the college/university program or clinical
director verifying at least 325 graduate clinical practicum hours in each discipline and that the program is
consistent with the standards of the state universities of Kansas, or approved by the Secretary.
FULL/RECIPROCAL LICENSE
Applicants for a full/reciprocal license must submit either university documentation of clinical practicum OR certificate of
clinical competence.
SUPERVISED POSTGRADUATED PROFESSIONAL EXPERIENCE
TEMPORARY LICENSE
Have you completed a supervised postgraduate professional experience of at least 9 months full-time, or its equivalent?
Y/N
If NO, complete and return the “Supervised Postgraduate Professional Experience Plan.”
If YES, complete and return the “Supervised Postgraduate Professional Experience Documentation.”
FULL/RECIPROCAL LICENSE
Applicants requesting a full/reciprocal license may submit either documentation of completing the experience signed by
the supervisor OR a Certificate of Clinical Competence.
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