Section R9-16-204. Application for a Temporary License for a Speech-Language Pathologist License

A.      An applicant for a temporary speech-language pathologist license shall submit to the Department:

1.        An application in a format provided by the Department that contains:

a.         The applicant's name, home address, telephone num- ber, and e-mail address;

b.        The applicant’s Social Security number, as required under A.R.S. §§ 25-320 and 25-502;

c.         If applicable, the applicant’s business address and telephone number;

d.        If applicable, the name of the applicant's employer, including the employer’s business address and tele- phone number;

e.         Whether the applicant has ever been convicted of a felony or a misdemeanor involving moral turpitude in this or another state;

f.         If the applicant has been convicted of a felony or a misdemeanor involving moral turpitude:

i.         The date of the conviction,

ii.        The state or jurisdiction of the conviction,

iii.      An explanation of the crime of which the appli- cant was convicted, and

iv.       The disposition of the case;

g.        Whether the applicant is or has been licensed as a speech-language pathologist in another state or country;

h.        Whether the applicant has had a license revoked or suspended by any state within the previous two years;

i.         Whether the applicant is currently ineligible for licensing in any state because of a license revocation or suspension;

j.         Whether any disciplinary action, consent order, or settlement agreement is pending or has been imposed by any state or country upon the applicant's speech-language pathologist license;

k.        Whether the applicant agrees to allow the Depart- ment to submit supplemental requests for informa- tion under R9-16-209;

l.         An attestation that the information submitted is true and accurate; and

m.       The applicant’s signature and date of signature;

2.        If applicable, a list of all states and countries in which the applicant is or has been licensed as a speech-language pathologist;

3.        If a license for the applicant has been revoked or sus- pended by any state within the previous two years, docu- mentation that includes:

a.         The date of the revocation or suspension,

b.        The state or jurisdiction of the revocation or suspen- sion, and

c.         An explanation of the revocation or suspension;

4.        If the applicant is currently ineligible for licensing in any state because of a license revocation or suspension, docu- mentation that includes:

a.         The date of the ineligibility for licensing,

b.        The   state  or  jurisdiction   of  the  ineligibility  for licensing, and

c.         An explanation of the ineligibility for licensing;

5.        If the applicant has been disciplined by any state, territory or district of this country for an act related to the appli- cant's speech-language pathologist license that is grounds for disciplinary action under Title 37, Chapter 17, docu- mentation that includes:

a.         The date of the disciplinary action;

b.        The state or jurisdiction of the disciplinary action;

c.         An explanation of the disciplinary action; and

d.        Any other applicable documents, including a legal order or settlement agreement;

6.        A copy of the applicant’s:

a.         U.S. passport, current or expired;

b.        Birth certificate;

c.         Naturalization documents; or

d.        Documentation of legal resident alien status;

7.        Documentation of the applicant’s:

a.         Official transcript issued to the applicant by an accredited college or university after the applicant's completion of a master’s degree consistent with the standards of this state’s universities, as required in A.R.S. § 36-1940.01(A)(2)(a); and

b.        Completion of a clinical practicum, as required in A.R.S. § 36-1940.01(A)(2)(b);

8.        A copy of the applicant’s clinical fellowship agreement that includes:

a.         The applicant’s name, home address, and telephone number;

b.        The clinical fellowship supervisor's name, business address, telephone number, and Arizona speech-lan- guage pathology license number;

c.         The name and address where the clinical fellowship will take place;

d.        A statement by the clinical fellowship supervisor agreeing to comply with R9-16-210; and

e.         The signatures of the applicant and the clinical fel- lowship supervisor;

9.        Documentation of the applicant’s completion of the ETS- NESLP as required in A.R.S. § 36-1940.01(A)(3); and

10.     A nonrefundable $100 application fee.

B.       A temporary license issued is effective for 12 months from the date of issuance.

C.      A temporary license may be renewed only once.

D.      An applicant issued a temporary speech-language pathologist license shall:

1.        Practice under the supervision of a licensed speech-lan- guage pathologist, and

2.        Not practice under the supervision of individual who has a temporary speech-language pathologist license.

E.       The Department shall review an application packet for a tem- porary speech-language pathologist license according to R9- 16-209 and Table 2.1

Historical Note

Former Section R9-16-204 repealed, new Section R9-16- 204 adopted effective January 23, 1978 (Supp. 78-1).

Repealed effective March 14, 1994 (Supp. 94-1).

Adopted by final rulemaking at 5 A.A.R. 4359, effective October 28, 1999 (Supp. 99-4). Amended by final

rulemaking at 10 A.A.R. 2063, effective July 3, 2004 (Supp. 04-2). Section R9-16-204 renumbered to R9-16- 209; new Section R9-16-204 made by exempt rulemaking at 20 A.A.R. 1998, effective July 1, 2014 (Supp. 14-2).