Sample Application
for ASHA Certification

This page is intended to help MA students of the Hearing and Speech Sciences program of the University of Maryland at College Park fill out their application for ASHA certification.
It provides a sample for how to fill out the following sections of the application.

BASIC SCIENCE COURSE WORK (continued)

BASIC HUMAN COMMUNICATION PROCESSES

10

Course
Number

11

Full course title
(as it appears on transcript)

 13
Graduate
Semester
Credit Hrs.
(check)		 17

Semester
Credit Hrs.
(list)
       

Anatomic and Physiologic Bases (List a least one course)
HESP311 Anatomy Pthg & Physio   3
HESP305 Anat & Phys. Spch Mech.   3
       

Physical and Psychophysical Bases (List at least one course)
HESP600 Instrumentation V 3
HESP604 Acous & Percpt Phonetics V 3
HESP403 Intro to Phonetic Science   3
HESP407 Bases of Hearing Science   3
       
Linguistic and Psycholinguistic Aspects (List at least one course)
HESP120 Intro Linguistics   3
HESP300 Intro Psycholinguistics   3
HESP400 Spch & Lang Dev Chil   3
       

PROFESSIONAL COURSE WORK - SLP - Audiology student version

10

Course
Number

11

Full course title
(as it appears on transcript)

 13
Graduate
Semester
Credit Hrs.
(check)		 17

Semester
Credit Hrs.
(list)
       

Speech Disorders
HESP702 Diagn Proc for SLP V 1.5
HESP612 Fluency Dis V 3
HESP402 Sp Path I (Phonol Dis)   1.5
HESP404 Sp Path II   3
HESP406 Sp Path III (Dysarthria)   1.5
HESP620 Phono + Articu Disorders V 3
       

Language Disorders
HESP616 Lang Dis in Children V 3
HESP402 Sp Path I (Lang Dis-Child)   1.5
HESP406 Sp Path III (Aphasia)   1.5
HESP610 Aphasia V 3
HESP702 Diagn Proc for SLP V 1.5

PROFESSIONAL COURSE WORK - CCC/A (Audiology student version)

10

Course
Number

11

Full course title
(as it appears on transcript)

 13
Graduate
Semester
Credit Hrs.
(check)		 17

Semester
Credit Hrs.
(list)
       

HEARING Disorders
HESP411 Intro to Audiology   3
HESP417 Prn & Mth Path & Audio   3
HESP606 Basic Hearing Meas V 3
HESP630 Electrophysio Measrmt V 3
HESP638 Minor Research Prct V 3
HESP639 Noise Control Lab V 3
HESP645 Pediatric Audiology V 3
HESP649A Diag Audiology Prac Sem *
HESP706 Adv Clin Audiology V 3

Habilitation/Rehabilitation Procedures
HESP700 Hearing Aids V 3
HESP635 Aural Rehabilitation V 3
HESP649B Aural Rehabilitation Prac Sem *

* A maximum of 6 academic semester credit hours associated with clinical practicum may be counted toward the minimum of 36 semester credit hours of professional work, but those hours may not be used to satisfy the minimum of 6 semester credit hours in hearing disorders/evaluation, 6 hours in speech-language pathology, or the 21 graduate semester hours required in the area in which certification is sought

 

18) CLINICAL PRACTICUM (Audiology)

Applicant=s Name (Print or Type)

Twenty-five clock hours of observation must be completed before beginning practicum.

Note: The supervisor=s name should correspond to the specific clock hours supervised.

A. AUDIOLOGY

Children

Supervisor=s

Full Name

(inc. maiden & middle)

 College/Univ Supervisor=s

ASHA Account

Number

 Supervisor=s

CCC Area

 Name of Practicum Site Practicum

Completion

Date (mo/yr)

 Record hours under areas in which they were obtained TOTAL HOURS
Selection and Use of Amplification &

Assistive Devices

 Evaluation Treatment Related

Disorders

 Staffing

Hours
Marilyn Kay RO131 56789123 Aud UMCP 12/10/96 5 20   3   28
                       
                       
Janice Jones RO131 23456789 Aud Washington Hospital 12/10/97 5 20     3 28
                       
Jane E. Doe Ro131 22222222 Aud P.G. County Parent 5/14/98 25 5 15   2 47
        Infant Program              
                       
          TOTALS 35 45 15 3 5 103

Adults

Supervisor=s

Full Name

(inc. maiden & middle)

 College/Univ Supervisor=s

ASHA Account

Number

 Supervisor=s

CCC Area

 Name of Practicum Site Practicum

Completion

Date (mo/yr)

 Record hours under areas in which they were obtained TOTAL HOURS
Selection and Use of Amplification &

Assistive Devices

 Evaluation Treatment Related

Disorders

 Staffing

Hours
Helen May RO262 89112345 Aud Penn State Univ. 5/12/96   5 1     6
                       
Marilyn Kay RO131 56789123 Aud UMCP 12/10/96 11 43       54
                       
Nancy G. Jones RO131 34567891 Aud UMCP 5/13/97 20 35   3   58
                       
Mary J. Smith RO131 12345678 Aud Holiday Park Senior 5/13/97     18     18
        Center              
                       
Jane M. Smith RO131 45678912 Aud Veterans Admin. 8/15/98 27 52   2 3 84
          TOTALS 58 135 19 5 3 220

B. SPEECH-LANGUAGE PATHOLOGY (for audiology majors) ELIZABETH SMITH Applicants Full Name (Print or Type)

Supervisor=s

Full Name

(inc. maiden & middle)

 College/

Univ

 Supervisor=s ASHA Account Number Supervisor=s

CCC Area

 Name of Practicum Site Practicum Completion Date (mo/yr) Record hours under areas in which they were obtained.
Evaluation/Screening Treatment
Speech Disorders Language Disorders Speech Disorders Language Disorders
Tracy Thom RO262 89123456 SLP Penn State 5/12/96     10  
                   
Leslie Lee RO131 78912345 SLP UMCP 4/13/97     20  
                   
Jennifer Jones RO131 67891234 SLP UMCP 7/15/97 10 6    
           

16

30
           

46

 

C. SUMMARY OF CLINICAL PRACTICUM HOURS

Hours

Observation total clock hours: 25

Clinical Practicum total clock hours: 369

Hours in Audiology: 323

Hours in Audiology at graduate level: 317

Hours in Speech-Language Pathology: 46

Date all hours were completed: 8/15/98

  At least 50 hours of practicum must be completed in each of three types of clinical settings. List the setting in which these hours were completed.

1. University Clinic

2. Public Schools

3. Hospital Clinic

     

I verify that all practicum information listed above was completed at according to all ASHA practicum requirements and that at least 25 hours of observation were acquired before the practicum was begun. Name of university

Program director=s signature Date

PROFESSIONAL COURSE WORK - SLP (SLP student version)

10

Course
Number

11

Full course title
(as it appears on transcript)

 13
Graduate
Semester
Credit Hrs.
(check)		 17

Semester
Credit Hrs.
(list)
       

Speech Disorders
HESP612 Fluency Dis V 3
HESP614 Oral Facial Anomalies V 3
HESP620 Phon & Artic Disorders V 3
HESP622 Neuromotor dis. of speech V 3
HESP624 Voice Disorders V 3
HESP639B Dysphagia V 3
HESP648 Clinical practice in speech V *
HESP702 Diagn Proc for SLP V 1.5

Language Disorders
HESP610 Aphasia V 3
HESP616 Lang Disorders in Children V 3
HESP626 Lang and Learning Disabil. V 3
HESP702 Diagn Proc for SLP V 1.5

* A maximum of 6 academic semester credit hours associated with clinical practicum may be counted toward the minimum of 36 semester credit hours of professional work, but those hours may not be used to satisfy the minimum of 6 semester credit hours in hearing disorders/ evaluation, 6 hours in speech-language pathology, or the 21 graduate semester hours required in the area in which certification is sought.

PROFESSIONAL COURSE WORK - CCC/A (SLP student version)

10

Course
Number

11

Full course title
(as it appears on transcript)

 13
Graduate
Semester
Credit Hrs.
(check)		 17

Semester
Credit Hrs.
(list)
       

HEARING Disorders
HESP411 Intro to Audiology   1.5
HESP606 Basic Hearing Meas V 3
HESP649A Diag Audiology Prac Sem *

Habilitation/Rehabilitation Procedures
HESP700 Intro to Audiology   1.5
HESP635 Aural Rehabilitation V 3
HESP649B Aural Rehabilitation Prac Sem *

* A maximum of 6 academic semester credit hours associated with clinical practicum may be counted toward the minimum of 36 semester credit hours of professional work, but those hours may not be used to satisfy the minimum of 6 semester credit hours in hearing disorders/evaluation, 6 hours in speech-language pathology, or the 21 graduate semester hours required in the area in which certification is sought

19) CLINICAL PRACTICUM (Speech-Language Pathology)

Applicant=s Full Name (Print or Type): Elizabeth Smith

Twenty-five clock hours of observation must be completed before beginning practicum.

Note: The supervisor=s name should correspond to the specific clock hours supervised.

a. Evaluation Children

Supervisor=s

Full Name

(inc. maiden & middle)

 College/Univ Supervisor=s

ASHA Account

Number

 Supervisor=s

CCC Area

 Name of Practicum Site Practicum

Completion

Date (mo/yr)

Record hours under areas in which they were obtained

 TOTAL HOURS
 

Speech Disorders

      
Language
Disorders		 Articulation
Disorders		 Voice
Disorders		 Fluency
Disorders		 Dysphagia Related
Disorders		 Staffing
Hours
Mehta-Lynn Guistics   00220022 SP UMCP 4/25/97 2.0 5.0           7.0
Horace Voyce                          
Stan Murring                          
Cybal Lant   23456789 Aud Washington Hospital 12/10/97 5 20     3     28
Constance Kluster                          
Lauren Jeey!   22222222 Aud P.G. County Parent 5/14/98 25 5 15   2     47
        Infant Program                  
                           
          TOTALS 35 45 15 3 5     103

Adults

Supervisor=s

Full Name

(inc. maiden & middle)

 College/Univ Supervisor=s

ASHA Account

Number

 Supervisor=s

CCC Area

 Name of Practicum Site Practicum

Completion

Date (mo/yr)

 Record hours under areas in which they were obtained TOTAL HOURS
Selection and Use of Amplification &

Assistive Devices

 Evaluation Treatment Related

Disorders

 Staffing

Hours
Helen May RO262 89112345 Aud Penn State Univ. 5/12/96   5 1     6
                       
Marilyn Kay RO131 56789123 Aud UMCP 12/10/96 11 43       54
                       
Nancy G. Jones RO131 34567891 Aud UMCP 5/13/97 20 35   3   58
                       
Mary J. Smith RO131 12345678 Aud Holiday Park Senior 5/13/97     18     18
        Center              
                       
Jane M. Smith RO131 45678912 Aud Veterans Admin. 8/15/98 27 52   2 3 84
          TOTALS 58 135 19 5 3 220

B. SPEECH-LANGUAGE PATHOLOGY (for audiology majors) ELIZABETH SMITH Applicants Full Name (Print or Type)

Supervisor=s

Full Name

(inc. maiden & middle)

 College/

Univ

 Supervisor=s ASHA Account Number Supervisor=s

CCC Area

 Name of Practicum Site Practicum Completion Date (mo/yr) Record hours under areas in which they were obtained.
Evaluation/Screening Treatment
Speech Disorders Language Disorders Speech Disorders Language Disorders
Tracy Thom RO262 89123456 SLP Penn State 5/12/96     10  
                   
Leslie Lee RO131 78912345 SLP UMCP 4/13/97     20  
                   
Jennifer Jones RO131 67891234 SLP UMCP 7/15/97 10 6    
           

16

30
           

46

 

C. SUMMARY OF CLINICAL PRACTICUM HOURS

Hours

Observation total clock hours: 25

Clinical Practicum total clock hours: 369

Hours in Audiology: 323

Hours in Audiology at graduate level: 317

Hours in Speech-Language Pathology: 46

Date all hours were completed: 8/15/98

  At least 50 hours of practicum must be completed in each of three types of clinical settings. List the setting in which these hours were completed.

1. University Clinic

2. Public Schools

3. Hospital Clinic

     

I verify that all practicum information listed above was completed at according to all ASHA practicum requirements and that at least 25 hours of observation were acquired before the practicum was begun. Name of university

Program director=s signature Date