Behavior Analyst Certification Board | Organization Final Experience Verification Form
Version 08/2019 | Copyright © 2019, BACB® | All rights reserved.
Experience Verication Form:
Multiple Supervisors at One Organization
FINAL
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): ____________
Responsible Supervisor Information and Attestation
Responsible Supervisor Name: _______________________________ BACB Account ID: _____________ Qualification: __________________
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 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.
All supervisors, including the responsible supervisor, met BACB supervision requirements during these experience hours.
I am the responsible supervisor designated in the signed supervision contract with this trainee.
Signature:
_________________________________________________________________________________ Date: __________________
Instructions: Please complete one form per organization, 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.
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Supervisors at the Organization
Supervisor Name: ___________________________
BACB Account ID: ____________ Qualification: __________________
Supervisor Name: ___________________________
BACB Account ID: ____________ Qualification: __________________
Supervisor Name: ___________________________
BACB Account ID: ____________ Qualification: __________________
Supervisor Name: ___________________________
BACB Account ID: ____________ Qualification: __________________
Supervisor Name: ___________________________
BACB Account ID: ____________ Qualification: __________________
Supervisor Name: ___________________________
BACB Account ID: ____________ Qualification: __________________
Supervisor Name: ___________________________
BACB Account ID: ____________ Qualification: __________________
Supervisor Name: ___________________________
BACB Account ID: ____________ Qualification: __________________
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