Revised: 04-15-14 2026

1. Click ‘Get Form’ to open the application for certification in the editor.
2. Begin with SECTION A by entering your name, present address, Nebraska license number, and the area in which the assistant is working. Ensure all fields are filled accurately.
3. Proceed to SECTION B to provide the name of the audiology or speech-language pathology assistant you are supervising. Indicate if you supervise other assistants and list their names and hours as required.
4. In SECTION C, fill out the practice site locations where the assistant will work. Include facility names, addresses, and optional telephone numbers.
5. Move to SECTION D to indicate which duties the assistant will perform by checking the appropriate boxes. Provide a description of how an alternate supervisor will be utilized when necessary.
6. Finally, complete SECTION E by attesting your responsibilities as a supervisor. Sign and date where indicated.

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