Slp Form 100 - Louisiana Board Of Examiners For Speech Language Page 2
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1
2Alternative
Record the number of alternative monitoring activities quarterly if a
Monitoring Activities
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
Review of screening
results
Review of diagnostic
reports
Review of treatment
plans, IEPs, etc.
Review of other client
records
Telephone/electronic
communications
In-service meetings/
Trainings attended by
licensee
Review of audio or
video tapes relevant to
specific patients/clients
Other
TOTAL NUMBER OF ALTERNATIVE MONITORING ACTIVITIES
(whether 12 or 9 month employee )
PERIOD OF SUPERVISION: _______________________________ to ________________________________
(Month, Day and Year)
(Month, Day and Year)
We hereby certify to the Louisiana Board of Examiners for Speech-Language Pathology and Audiology
that the above statements are true and correct.
__________________________________________
___________________________________________
Supervisor’s Signature
Supervisee’s Signature
__________________________________________
___________________________________________
Supervisor’s Printed Name
Supervisee’s Printed Name
__________________________________________
___________________________________________
Supervisor’s Address
Supervisee’s Address
__________________________________________
___________________________________________
Supervisor’s Address
Supervisee’s Address
__________________________________________
___________________________________________
Supervisor’s License Number
Supervisee’s License Number
Louisiana Board of Examiners for Speech-Language Pathology and Audiology
18550 Highland Road, Suite B Baton Rouge, Louisiana 70809
Telephone: (225) 756-3480 or (800) 246-6050
Website: Email:
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