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Form 4B - Record of Supervised Experience

At the end of the supervised experience, your supervisor must send this form directly to the Office of the Professions as directed at the end of the form. The Office of the Professions will not accept this form if it is submitted by the applicant. 

  • Section I: Complete this section before sending the entire form to your supervisor. Be sure to sign and date item 7 once the supervised experience is complete.
  • Section II: Your supervisor must review this section and complete the attestation then return both pages of the form directly to the Office of the Professions at the address at the end of the form.

If you completed your experience in the past and are certified by the American Speech-Language Hearing Association (ASHA), you can request ASHA submit a verification statement directly to the Office of the Professions at:

New York State Education Department
Office of the Professions
Division of Professional Licensing Services
Speech-Language Pathology and Audiology Unit
89 Washington Avenue
Albany, NY 12234-1000
Phone: 518-474-3817 ext. 270
Fax: 518-402-5354
E-mail: DPLSExperience@nysed.gov