The Kentucky Board of Speech-Language Pathology and Audiology
P.O. Box 1360
Frankfort, KY 40602
POSTGRADUATE PROFESSIONAL EXPERIENCE REPORT FOR
INTERIM SPEECH-LANGUAGE PATHOLOGY ASSISTANTS
Please print. An application for permanent licensure must be submitted at this time if you have not already done so. NOTE: A separate PPE REPORT MUST BE SUBMITTED FOR EACH CHANGE IN SITE, SUPERVISION OR HOURS PER WEEK.
I. Name of Interim Licensee: ___________________________________________________________________________________
Last First Middle Maiden
Address: _____________________________________________________________________________________________
Street City State Zip Code
Home Telephone Number ( ) ____________________________ Social Security Number _________________________
Academic Status: ______________________________________________________________________________________
Graduate University Degree Date Conferred
Kentucky Interim License Number ____________________________ Date Licensed _______________________________
II. PPE Supervisor: ___________________________________________________________________________________________
Last First Middle Maiden
Address: _____________________________________________________________________________________________
Street City State Zip Code
Telephone Number: Home ( ) _______________________________________ Work ( ) _______________________
Place of Employment: __________________________________________________________________________________
Facility Name/School System
Credential Information: [ ] Kentucky SLP License # ________________ [ ] Teacher Certification # ______________
III. PPE Setting: _____________________________________________________________________________________________
School System
Address: ____________________________________________________________________________________________
Street City State Zip Code
Telephone Number: ( ) ____________________________________
IV. Beginning Date of PPE ______/______/______ Ending Date of PPE ______/______/______
— Full-Time (9 months) — Part-Time: ________ hrs/week ________ # weeks
— This report is only for a portion of my PPE (Please attach explanation.)
Specify how many hours per week were spent in the following activities:
____________ Evaluation
____________ Screening
____________ Habilitation/Rehabilitation (direct and indirect services)
____________ Reports
____________ In-Service Training
____________ Other (specify here): __________________________________________________________________________
____________ Total hours per week
Complete Chart A indicting the number of direct and indirect supervision hours completed during each four week period. Refer
to Chart B for the required number of weeks and complete Chart A only for the weeks that this report covers.
If you have changed from one category to another in Chart B (e.g. switched from 16 to 35 hours per week), you must submit a
separate report for each category.
Chart A: PPE Supervision
Weeks of PPE
Number of Direct
Supervision Hours (minimum of 3 hours per week)
Number of Indirect
Supervision Hours
(minimum of 3 hours per week)
Week 1-4
Week 5-8
Week 9-12
Week 13-16
Week 17-20
Week 21-24
Week 25-28
Week 29-32
Week 33-36
Week 37-40
Week 41-44
Week 45-48
Week 49-52
Week 53-56
Week 57-60
Week 61-64
Week 65-68
Week 69-72
Total Hours
Chart B: Required Number of Weeks for PPE
Hours worked per week:
Required length of PPE:
30+ hours/week
9 months (36 weeks)
25-29 hours/week
12 months (48 weeks)
20-24 hours/week
15 months (60 weeks)
15-19 hours/week
18 months (72 weeks)
VII. I hereby certify that all information by me on this form is true and complete to the best of my knowledge.
SIGNATURE OF INTERIM SLPA LICENSE ____________________________________________ DATE ______________
VIII. AS THE SUPERVISOR, DO YOU RECOMMEND THAT THIS INTERIM LICENSEE’S PPE REPORTED ABOVE BE
APPROVED BY THE KENTUCKY BOARD OF SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY TOWARDS
MEETING THE REQUIREMENTS FOR PERMANENT LICENSURE AS A SPEECH-LANGUAGE PATHOLOGY
ASSISTANT?
[ ] YES [ ] NO (Note: If no, please attach letter of explanation)
IX. I have discussed this report with the interim licensee. Furthermore, I certify that my credentials were current throughout this PPE. I have completed and attached the required evaluation form.
SIGNATURE OF SUPERVISOR ________________________________________________________ DATE __________________