1
Speech-Language Pathologist & Audiologist Licensing
Continuing Education Reporting Form
Name: ____________________________________
License #: _________________________________
Continuing Education (CE) Report Due Date: _____
Daytime Phone #: __________________________
1. Practice Area:
______Speech Language Pathologist (SLP)
______Audiologist (AUD)
______Dual (SLP-AUD)
2. Do you hold a current Minnesota teaching license as a SLP with the MN Professional Educator Licensing &
Standards Board (PELSB)?
______Yes
_____ No
3. If yes, are you reporting activities that meet PELSB CE requirements to meet MDH SLP CE requirements?
______Yes
______No
If yes, complete the Affirmation of Speech-Language Pathologist Holding a MN PELSB License form
(https://www.health.state.mn.us/facilities/providers/slpa/docs/slpaffir.pdf) and attach it with this form.
Submitting this form
Please upload your completed CE Reporting Form with your renewal application in the ICSD license renewal
portal (https://icsd.web.health.state.mn.us/security/login.do). Your login information is provided on the
renewal notice sent to you by mail.
Do not submit certificates of course completion or transcripts unless MDH requests this information. Please
retain your certificates of course completion or transcripts with a copy of this form for your records.
Continuing Education Requirements
Courses must be completed between the effective and expiration dates of the license. MN Statute 148.5193,
subdivision 1(b) requires licensees complete a minimum of 30 contact hours of continuing education within
the two years immediately preceding licensure expiration. A minimum of 20 contact hours must be directly
related to the licensee's area of licensure. Ten contact hours may be generally related to the licensee's area of
licensure.
For the table below, convert your CEUs into contact hours. For example, if 1 CEU equals 10 contact hours, then
multiple the number of CEUs by 10 to get the number of contact hours.
SPEECH LANGUAGE PATHOLOGIST & AUDIOLOGIST LICENSING CONTINUING EDUCATION REPORTING FORM
2
Name: __________________________________________________ License #: _______________________________________________
Title of workshop, presentation, seminar, or other
activity
Name of presenter, sponsor or
designee
Attendance date(s)
(mm/dd/yy)
Contact
hours
Directly or
Generally
Related?
SPEECH LANGUAGE PATHOLOGIST & AUDIOLOGIST LICENSING CONTINUING EDUCATION REPORTING FORM
3
Title of workshop, presentation, seminar, or other
activity
Name of presenter, sponsor or
designee
Attendance date(s)
(mm/dd/yy)
Contact
hours
Directly or
Generally
Related?
The above information is true and correct to the best of my knowledge and belief:
Signature: ________________________________________________ Date Signed: ______________________________________________
All pages must be signed and dated within 30 days of submission.
Minnesota Department of Health
Health Regulation Division
Health Occupations Program – SLP/AUD Licensing
PO Box 64882
St. Paul, MN 55164-0882
Phone: 651-201-4200
health.slpa@state.mn.us
www.health.state.mn.us
12/06/2021
To obtain this information in a different format, call: 651-201-4200.
