Behavior Analyst Certification Board | Individual Monthly Verification Form
Version 08/2019 | Copyright © 2019, BACB® | All rights reserved.
Supervisor Name: ___________________________________________ BACB Account ID: _________________________
Supervisor Qualification Type (Select One): BCBA/BCBA-D Verified Experience Instructor ABPP/ABA
Experience Hours (this month only)
A. Independent Hours (supervisor not present): ____________
B. Supervised Hours (supervisor present): ____________
Total Experience Hours (add A & B): ____________ Percent of Hours Supervised (Supervised/Total): ____________
Supervisor and Trainee Attestation
By signing below, we hereby attest that:
⊲ The information contained on this form is true and correct to the best of our knowledge;
⊲ The required number of supervisory contacts occurred during this month;
⊲ Observation of the trainee with a client occurred during this supervisory period with a frequency appropriate for this experience type;
⊲ The trainee was supervised for the required amount of time for this supervisory period;
⊲ We have read and understand the most relevant version of the Experience Standards;
⊲ We are only including appropriate behavior-analytic activities in our totals listed above; and
⊲ The experience hours obtained during this supervisory period are otherwise compliant with the Experience Standards.
Supervisor Signature:
__________________________________________________________________________ Date: ________________
Trainee Signature: _____________________________________________________________________________ Date: ________________
Instructions: Please complete one form per supervisor, per experience type.
T
rainee Name: ____________________________________ BACB Account ID: ______________
Experience Type (Select One): Supervised Independent Fieldwork Practicum Intensive Practicum
State Where Experience Occurred: ____________________________ Country Where Experience Occurred: ____________________________
Experience Verication Form:
Individual Supervisor
Month/Year: ______________
MONTHLY
This document must bear the signature (see the Acceptable Signatures Policy) of the supervisor and trainee and must be signed by the last day of the calendar month following the
month of supervision.
SUPERVISOR AND TRAINEE MUST EACH RETAIN A COPY OF THIS FORM FOR AT LEAST 7 YEARS.
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