Fillable BACB Final Experience Verification Form Individual 190827

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BACB Final Experience Verification Form Individual 190827

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Behavior Analyst Certification Board | Individual Final Experience Verification Form
Version 08/2019 | Copyright © 2019, BACB® | All rights reserved.
Experience Hours
A. Independent Hours (supervisor not present): ____________
B. Supervised Hours (supervisor present): ____________
Total Experience Hours (add A & B): ____________ Percent of Hours Supervised (Supervised/Total): ____________
Supervisor Information and Attestation
Supervisor Name: ___________________________________ BACB Account ID: _______________
Supervisor Qualification Type (Select One): BCBA/BCBA-D Verified Experience Instructor ABPP/ABA
Supervision Requirements Met? Yes No
By signing below, I hereby attest that:
⊲ Information presented on this Final Experience Verification Form and the corresponding Monthly Experience Verification Forms is true and correct to
the best of my knowledge.
⊲ The trainee completed the experience under my supervision in compliance with all relevant Experience Standards including, but not limited to; the
minimum number of contacts per month, required amounts of unrestricted activities, required observations each month with clients, and adherence
to the Professional and Ethical Compliance Code for Behavior Analysts.
⊲ I am the supervisor designated in the signed supervision contract with this trainee.
Signature:
_________________________________________________________________________________ Date: ___________________
Instructions: Please complete one form per supervisor, per experience type.
Trainee Name: ____________________________________
BACB Account ID: _____________ Start Date: _______ End Date: _______
Experience Type (Select One): Supervised Independent Fieldwork Practicum Intensive Practicum
State Where Experience Occurred: ____________________________ Country Where Experience Occurred: ____________________________
This document must be signed in accordance with the Acceptable Signatures Policy.
SUPERVISOR AND TRAINEE MUST EACH RETAIN A COPY OF THIS FORM FOR AT LEAST 7 YEARS.
Experience Verication Form:
Individual Supervisor
FINAL
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BACB Final Experience Verification Form Individual 190827

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Completed 18 July 2020

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