SPEECH-LANGUAGE PATHOLOGIST AUDIT OF COMPLIANCE FORM Name

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First

SLP Certificate #

Date

Complete and return this form to demonstrate how you complied with continuing competency (CC) requirements from December 1, 2014 through November 30, 2015 (or the date your certificate was renewed). For more information, visit the Office of Speech-Language Pathology Certification Continuing Professional Competency website at www.colorado.gov/dora/Speech-Language_Pathology_CPC. Choose the method of how you complied with CC requirements during the 2014-2015 renewal period (check one box):

1)

□ Deemed Status – Check this box if you complied with CC requirements by meeting the continuing professional competency requirements of the Colorado Department of Education (CDE). To claim Deemed Status, for the entire DORA renewal period you must have been employed by a school district, held an Active special services provider license with CDE AND been in compliance with their CC requirements. With this completed form, submit all of the following: 1) Verification of employment letter from your employer, must include your dates of employment, AND 2) a copy of your CDE special services provider license.

2)

□ Continuing Professional Development (CPD) program – Check this box if you complied with CC requirements by completing the CPD program. Complete Steps 1-3: Step 1: Submit your completed Learning Plan. If you created more than two learning goals, submit those additional forms. Step 2: Detail completion of each activity in the chart below (attach additional pages as needed). Accrual of 10 Professional Development Activities (PDA) per 1-year renewal period is required. Review the Professional Development Activities (PDA) List and the CPC Program Manual to determine how to categorize PDA. No more than five hours will be credited in any one category, except Coursework. All 10 PDA can be completed in the category of Coursework. The acceptable Categories are: Volunteer Service Mentoring/Supervision Presenting

Coursework Independent Learning Group Study

PDA must be directly relevant to your practice and pertinent to your learning goals. Credit will be given if the activity is included in the PDA List. The Director may accept or reject activities submitted for consideration that are not identified on the PDA List. All PDA must be completed during the renewal period and will only count for that 1-year renewal period. Step 3: Submit required documentation for each activity according to the PDA List and this completed form. Enter Goal # (copy from Learning Plan) Examples: 1

Enter PDA Category

2

Volunteer Service

9News Health Fair

3

Group Study

Study Group: Ethics & Compliance

3

Independent Learning

Journal Article: Documentation Made Easy

Identify Activity Completed

Coursework

Include the following: Name of the activity and provider (as applicable) Spanish 101 Community College of Denver

Date Activity # PDA Completed Completed Dec 20, 2014

3

April 15, 2015

4

Sept 1, 2015

2

Nov 1 2015

Rev. 4/2016

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Page 1

Enter Goal # (copy from Learning Plan)

Identify Activity Completed Enter PDA Category

Include the following: Name of the activity and provider (as applicable)

# PDA Date Activity Completed Completed

Total PDA Completed :

0

I attest that I have met continuing competency requirements pursuant to §12-43.7-107, C.R.S. and the Office of Speech Language Pathology Certification Rule 9 and that the information contained on this form is true and correct to the best of my knowledge. I understand that pursuant to §12-43.7-110(2)(k), C.R.S., fraud, misrepresentation or deception in renewing a certification may be grounds for discipline. Signature

Date

Rev. 4/2016

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