Responsibility Statement for Supervision of a Speech-Language Pathology Assistant (77S-60, Rev 5 22) 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part A: Enter the full legal name, license number, street address, city, state, zip code, and email address of the Speech-Language Pathology Assistant.
3. Proceed to Part B: Fill in your full legal name as the supervisor, along with your license number or credential document number and contact details.
4. In Part C: Indicate the date supervision began and answer whether you are supervising an assistant with multiple supervisors. If yes, specify if you will be the lead supervisor.
5. Review and sign the duties and responsibilities section. Ensure all statements are accurate before signing on pages 2 and 3.
6. Finally, submit the completed form within 30 business days from the start date of supervision as required by regulations.

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