Behavior Analyst Certification Board | Individual Final Experience Verification Form
Version 07/2020 | 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): ____________
This experience included prorated hours for partial months.
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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