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SPECIALTY BOARD ON FLUENCY DISORDERS
BRS-FD THREE-YEAR RENEWAL FORM
In order to maintain your BRS-FD status, the
following is required: Payment of Annual Fee of
$70.00 Verification of Active Clinical
Practice Summary of Continuing
Education: 4.5 CEU’s or 45 Hours over Documentation of CE Activities Copy of Current ASHA Membership
Card (or some other proof of
________________________________________________________________________________________ PLEASE PRINT CLEARLY OR TYPE THE
FOLLOWING INFORMATION Name
____________________________________________________ Professional Address Org_______________________________________________________ Street_____________________________________________________ Suite/Floor_________________________________________________ City/State/Zip_____________________________________________
Phone_____________________________________________________ Professional Email
____________________________________ Professional Web
site__________________________________ Fax______________________________________________________ ASHA
#______________________________________________ Part 1
Professional Activities I attest that during the last
three years I have maintained a per year minimum of 100 clock hours of
active involvement in clinical management activities with individuals who
stutter. These activities are broadly defined and include diagnosis, treatment,
clinical supervision, referrals, consulting, and treatment maintenance
activities. Signature______________________________
Date__________________ EXAMPLES OF PROFESSIONAL
ACTIVITIES: A. Direct Contact With
Fluency Disordered Clients (Assessment,
Individual Treatment, Group Treatment) B. Supervision of Students
Providing Assessment or Treatment of Fluency Disordered Clients
(Individual and/or Group) C. Consultation Concerning
Fluency Disordered Clients (Parent or
Family Counseling as well as discussion of issues with other
Speech-Language Pathologists and other Professionals) D. Attending Fluency
Disorders Support Group Meetings as a Speaker, Facilitator, and/or Participant.
(These hours cannot account for more than
25% of the total hours of clinical management needed to maintain
specialization). Part 2 Continuing Education
4.5 CEU’s accrued over the
last three year period are required. Seven
broad areas of activity can be credited toward renewal. The 4.5 CEU requirement
can be met by activities in a single area or may be distributed across all seven
areas. You must provide: 1) a summary and 2)
documentation of these activities. A. SUMMARY OF CONTINUING
EDUCATION ACTIVITIES Referring to the enclosed
guidelines, on a separate sheet, please list (typed, please) your CE activities
with the following areas as a guide and provide the TOTAL number of CEU’S
at the end. Please include the following information:
Professional Meetings
Workshops Post
Masters degree courses: Audited Post
Masters degree courses: For Credit
Presentations
Publications Self
Study The following section summarizes
and provides examples of activities that can meet SBFD requirements. Please
note that the activities listed under each continuing education category are
only examples; they do not represent an exhaustive listing of acceptable
activities. If applicants are uncertain about the acceptability of activities,
they should contact the Board for clarification before submitting their renewal
materials. Examples and Suggested
Documentation for the Six Areas of CEU Activities Area 1 - Professional
Meetings: Examples: ASHA
Convention Division
4 Leadership Conference State
Speech-Language-Hearing Association Meetings IFA
Meetings Regional
and Local Conferences Within work facility departmental meetings, grand rounds,
guest lectures, etc. Documentation can include any
of the following: ASHA
Continuing Education Registry transcripts Meeting
program with proof of registration/attendance (e.g. receipt, attendee listing). For
within-work facility activities not associated with formal registration or ASHA
CEC documentation, a listing Of topics and hours, with signed verification by a
work supervisor. CEU Credits:
10 contact hours – 1 CEU Area 2 – Workshops
(including on-site workshops, seminars and
presentations, teleconferences, and
videoconferences; usually focused on a well- defined topic and presented one
or a few individuals) Examples:
ASHA-sponsored
teleconferences or video conferences
Workshops presented by hospitals, universities, schools, private corporations,
etc. Documentation can include any
of the following: ASHA
Continuing Education Registry transcripts Workshop
program with proof of registration/attendance (e.g.
receipt, attendee listing). For
within-work facility activities not associated with formal
registration or ASHA CEC documentation, a listing Of
topics and hours, with signed verification by a work supervisor. CEU Credits:
10 contact hours – 1 CEU Area 3 – Auditing Post-Masters
Courses & Self-Study or a few individuals)
Examples:
Auditing
graduate level courses Audio or
videotape presentations viewed as self-study Special
Interest Division 4 Newsletters read for self-study credit Journal
of Fluency Disorders articles read for self-study credit Other
ASHA-sponsored self-study activities Documentation can include any
of the following: For
audited courses, academic transcript or signed verification From
course instructor For
self-study activities, ASHA Continuing Education Registry
Transcripts or comparable documentation CEU Credits:
1 course (regardless of # of credits) = 1CEU 10 contact hours for
documented self-study – 1 CEU Area 4 – Completing
Post-Masters Courses for Credit Examples:
Academic
transcript or signed verification from course
Instructor (course must be passed) CEU Credits:
1 course (regardless of # of credits) = 2 CEUs Note:
Only 1.0 CEUs outside the area of fluency and fluency
disorders can be credited toward renewal. Area 5 - Presentation Examples:
Refereed
papers, poster sessions, and presentation at national state, or regional
professional meetings Invited
workshops, seminars, presentations, teleconferences, and videoconferences Graduate
level courses taught for credit (1 course = 1 presentation) Documentation:
Anything
that documents authorship, title of presentation, location, and date, such as
programs, brochures, letters of acceptance, course outlines, course catalogues,
published abstracts, etc. CEU Credits: 1
presentation = 1 CEU (regardless of duration of presentation) A
specific presentation given multiple times can be credited only once in the
three year renewal period. Area 6 – Publication Examples: Refereed
journal articles Invited
articles in refereed journals Refereed
or invited book chapters Books
Standardized published tests
Published abstracts and letters to the editor cannot be credited as
publications, but published abstracts can be used to document a presentation.
Documentation Any of
the following – reprint; first of the publication, but with complete
reference information; letter of manuscript acceptance CEU Credits:
1 publication – 2 CEUs Note:
Only 1.0 CEUs outside the area of fluency and fluency
disorders can be credited toward renewal. PLEASE PROVIDE THE TOTAL FOR
YOUR CEU’S B. PLEASE ATTACH THE REQUIRED
DOCUMENTATION FOR YOUR CEU’S RENEWAL CHECKLIST We thank you for taking the
time to put this information together. For your convenience, you can use the
following checklist to make certain all of your materials have been included: ____ Completed Three Year Renewal
Form: Contact Information ____ Your signature attesting to
your 100 annual clinical hours ____ Summary (list & total) of
your Continuing Education Activities ____ Attached documentation of
your CEU’s ____ A copy of your current ASHA
Membership Card (or some proof of maintenance of your CCC-SLP) ____ A check payable to ‘SBFD’ in
the amount of $70.00 Upon receipt of all of the above,
you remain a BRS-FD in good standing, your three-year renewal certificate will
be mailed to you and your listing on our web site will be maintained. Please contact us
with any questions. Thank you.
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