WHAT IS THE KASA FORM FOR?
The KASA form is to be used to document your undergraduate and graduate academic and clinical experiences. It MUST be submitted with your other ASHA forms when you seek director sign-off for certification. We will maintain a copy permanently in your files. The form posted here (in Excel format) is partially filled out to indicate which University of Maryland courses and clinical registrations potentially apply to the various categories. If you took eligible coursework, either graduate or undergraduate, at other institutions, you will need to insert that information yourself on the form. You may edit the form electronically, or print it out and write in your own additions/changes. Either way, the completed and printed form MUST accompany all applications for certification sent to Dr. Faroqi-Shah for signature. No ASHA CCC applications will be signed without completion of this worksheet.
WHEN SHOULD I FILL OUT MY KASA FORMS?
You have until the completion of your CFY to make sure that your KASA forms are complete and signed, although it may be easier to fill them out as you leave the academic program, when your memory for specific courses and assignments may be stronger.
WHO SIGNS MY KASA FORMS AND WHAT MUST I SUBMIT TO THE DEPARTMENT?
Dr. Faroqi-Shah MUST HAVE AN ENTIRELY COMPLETE APPLICATION to sign off on it. Any incomplete packets will be sent back. The KASA form is one part of a slightly longer application packet that includes your academic degree information, an affadavit regarding your testing and ethical background, the KASA form (the one on our website is a duplicate which is pre-populated with University of Maryland information for your convenience; it can substitute for the one in the ASHA web handbook), and a final page where Dr. Faroqi-Shah signs off on your completion and satisfaction of requirements.
In order for Dr. Faroqi-Shah to sign off on the entire application for certification, she must have
- The completed KASA form (Download the KASA form here)
- The Application for Certification completed in its entirety (CLICK HERE for materials and instructions)
- A final copy of your clinical clock hours
WHEN SHOULD I SUBMIT MY FORMS FOR DEPARTMENTAL SIGNATURE?
You have until completion of your CFY to submit these forms, or you can have them signed earlier and keep them to send to ASHA later. The department will keep a full copy of the application for you benefit should you need this information in the the future, since it is our understanding that ASHA will not maintain the full application after granting you certification.
Please submit your certification forms as a packet (not JUST the KASA form) for signature; this will prevent loss of portions of your materials which is inevitable when they are separated.
You have the following options when submitting them for Dr. Faroqi-Shah's signature:
- Drop off the full application and arrange to pick it up in person
- Provide us with a means to mail the application back to you (a properly stamped and addressed envelope)
YOU MAY NOT FAX THE INFORMATION TO US OR TO ASHA. THE FORMS DO NOT DUPLICATE WELL IN FAXING AND WE HAVE HAD TO RESUBMIT FAXED FORMS.
SAMPLE Knowledge and Skills Acquisition (KASA) SUMMARY FORM
