Slp Form 100 - Louisiana Board Of Examiners For Speech Language

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SLP FORM 100
Supervision Documentation for Provisional and
Restricted Speech-Language Pathologists
Supervision of Provisional or Restricted Speech-Language Pathologists must include a minimum of 12
monitoring activities annually. At least four (4) monitoring activities must be on-site, in-view
observations to be divided between the areas of diagnostics and management, supervised by an individual
holding a license in the area of speech-language pathology and issued by the Louisiana Board of Examiners
for Speech-Language Pathology and Audiology. Persons holding a Restricted, Provisional or Assistant
License may not serve as a supervisor. A supervising speech-language pathologist must have a minimum
of one year of full-time professional speech-language pathology experience following the postgraduate
professional/employment experience. Full-time employment in a school system for the school year is
considered to meet this requirement.
On-Site In-View Observation is defined as the supervisor observing the licensee engaging in a specified clinical
activity with his/her patient/client. The supervisor shall accomplish this task either by being physically present in the
room or through the use of a live video monitor.
Documentation of supervision may be requested by the Board. The supervision activities documented on this form
are to occur within the Board’s fiscal year, July 1 through June 30. This report should be mailed to the Board office
by June 30 of each year. At least four (4) monitoring activities must be on-site, in-view observations to be divided
between the areas of diagnostics and management. For twelve-month employees, one on-site, in-view observation
must be conducted each quarter. For nine-month employees, two on-site in-view observations must occur each
semester. It is also recommended that other monitoring activities be accomplished throughout the year of
supervision. On-site, in-view observations should last a minimum of one hour.
On-site in-view supervision as well as alternative methods of supervision must occur in every work setting in
which the licensee is employed/contracted. Licensees must remain under supervision until official
notification of licensure upgrade is received.
Place of Employment:
 Full time
 Part time
Check applicable
 9 month employee
 12 month employee
boxes:
 Hospital
 Private Practice
 Rehab/Agency
Setting:
 School
 University
 Other:___________________
On-Site, In-View
Record the number of on-site, in-view monitoring activities quarterly if
Monitoring Activities
a 12-month employee, or by semester if a 9-month employee.
12-month employees
9-month employees
ACTIVITY
ST
nd
rd
th
st
nd
1
Quarter
2
Quarter
3
Quarter
4
Quarter
1
2
Semester
Semester
Screening
Evaluation
Therapy
Family/Parent/Teacher
Conferences or
Consultations
TOTAL NUMBER OF ON-SITE, IN-VIEW OBSERVATIONS
(WHETHER 12 OR 9 MONTH EMPLOYEE)
AVERAGE NUMBER OF MINUTES PER SESSION
OVER 

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