Plan of Supervision for Apprenticeship Application

E-mail Address: *

Prefix:

First Name: *

Last Name: *

Apprentice Certificate number:

Sponsor's License Number: *

Sponsor Name:

Check all that apply: *

This is the Initial Plan of Supervision
Failed exam; will complete 15 hours of direct supervision each week.
Previously completed 750 hour requirement
This plan replaces the Plan of Supervision on file.
New Sponsor is reason for this plan being submitted.
I have an audiology license and will complete the 250 hour apprenticeship.
None of the above

21 NCAC 22A. 0311 defines Direct Supervision; Apprentice and Sponsor agree to obtain required hours in the three categories listed below. *

YES
NO

Component #1: On-site Inspection and Evaluation of Apprentice work will be ______ % of total required hours. *

Component #2: Consultation to review Apprentice activities will be ______% of total required hours. *

Component #3: Instruction provided to Apprentice for ______% of total required hours in the form of lectures, demonstrations, quizzes, etc. *

Additional explanation (if needed):

By submitting this form, both Sponsor and Apprentice acknowledge that it will become part of the Apprentice Application and the signature on that form will constitute a signature for this Plan of Supervision as well. *

YES
NO

* Required

You will receive immediate email confirmation with a copy of this submission when you click SUBMIT.

P.O. Box 97833, Raleigh, NC 27624-7833 - PH: 919.834.3661 - FAX: 919.834.3665 - Email: info@nchalb.org