Fill - Free fillable BACB Final Experience Verification Form Organization 190827 PDF form

Behavior Analyst Certiﬁcation Board | Organization Final Experience Veriﬁcation Form

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.

Note: This form contains

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Supervisors at the Organization