Texas Speech-Language-Hearing Association
Application for Independent Study

You must contact Independent Study Processor, Janice Stroud, at tshaplan@sbcglobal.net or
214-324-1773 / 214-321-7272 and have the plan approved before you begin your study.

Follow the instructions in the TSHA Independent Study brochure. Complete the following information
and return it to the Independent Study processor (payment $70 up to 3 hours plus $20 for each additional
block of 3 hours). Forms completed online must be submitted within 45 days. Summaries and other
materials may be attached to an email or mailed and are also due within 45 days. * Required Field

Participant's Name: 

Date: 

Address: 

City: 

State: 

Zip: 

Home Phone: 

Work Phone: 

Cell Phone: 

E-Mail: 

Texas SLP/AUD Lic #: 

TSHA Membership #: 

Month of Birth:  - Select - January February March April May June July August September October November December

Area of Study:  SLP  AUD

Title of Activity: 

Description of Activity:

Instructor or Presenter (if applicable)
Provide name, affiliation and brief description of qualifications:

Site of Activity: 

Actual Clock Hours Completed:   (max 20hrs/study)

Begin Date of Activity: 

Completion Date of Activity: 

Describe the learning objectives of this activity that are easy
to observe/measure with action verbs, such as analyze, create,
demonstrate, describe, develop, discover, discuss, explain, identify, etc.
As a result of my independent learning activity, I will...

Describe content, activities and materials for Activity

If mailed, send to:
Mrs. Janice E. Stroud
TSHA Independent Study
9336 Springwater
Dallas, Texas 75228