Board of Ethics Self-Report Form

To file a self-report with the ASHA Board of Ethics, please complete all required sections in the form below.

This Self Report Form should only be used by Certificate of Clinical Competence (CCC) holders, ASHA members, certified assistants, and applicants for ASHA certification/membership who are disclosing professional discipline or criminal convictions pursuant to Principal VI, Rule of Ethics (S) and/or (T) of the ASHA Code of Ethics, or Principal III, Conduct Fundamentals (O) and/or (P) of the Assistants Code of Conduct. You must attach copies of any convictions, final actions, or sanctions by a court or professional licensing/regulatory body to this form.

If you have any questions regarding the self-report process, please reach out to the ASHA Ethics Office at

After clicking “Submit” you will be redirected to the DocuSign website to digitally sign your submission. Do not exit your screen until you have completed the DocuSign signature process. We recommend that you review these DocuSign instructions prior to submitting this form.

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