Fillable Proposed Plan of Supervised Clinical Experience (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Proposed Plan of Supervised Clinical Experience (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Social Work Examiners
124 Halsey Street, 6th Floor, P.O. Box 45033
Newark, New Jersey 07101
(973) 504-6495
www.njconsumeraffairs.gov/sw
Proposed Plan of Supervised Clinical Experience
(This form should be completed by the supervisor and forwarded directly to the Board.)
Please print clearly.
I. SuperviseeInformation(LSW)
Name: __________________________________________________________________________________
Last Name First Name Middle Initial
Address: ________________________________________________________________________________
Street or P.O. Box City State ZIP Code
Daytime telephone number: ______________________ E-mail address: ______________________________
(include area code and extension)
Licensed Social Worker license number: ___________________________ Active as of: _________________
Date
II. Supervisor’sInformation(LCSW)
Name: __________________________________________________________________________________
Last Name First Name Middle Initial
Business Name: __________________________________________________________________________
Type of business (nonprot, for prot, group, private, etc.)
Business Address: _______________________________________________________________________
Street or P.O. Box City State ZIP Code
Telephone number: _________________________ E-mail address: _________________________________
(include area code and extension)
1. Do you hold a License as a Clinical Social Worker (LCSW) in the State of New Jersey for at least
three years? ☐ Yes ☐ No
A. License Number: __________________ B. Year Licensed: _______ C. Expiration Date: _______
2. When did you complete the 20 hour supervisory training (see N.J.A.C. 13:44G-8.1 (b)(3)(ii))?
_____________________________________ (Please include copy of certicate)
3. Have any of your licenses or certications ever been suspended, revoked or restricted in New Jersey
or any state or Jurisdiction? ☐ Yes ☐ No
If “Yes,” please provide details of the suspension or disciplinary action, including dates, location
and copies of any documents reecting such suspension or disciplinary action.
4. Does the proposed supervisor have any other individuals under clinical supervision (see N.J.A.C.
13:44G-8.1(f))? ☐ Yes ☐ No
If “Yes,” provide the names and license numbers of the other individuals and the total number of
supervisees:
Name License Number Name License Number
1. ____________________________________ 2. ____________________________________
3. ____________________________________ 4. ____________________________________
5. ____________________________________ 6. ____________________________________
Out-of-state Supervisors Only
(To be completed only if supervision is taking place outside of New Jersey.)
1. What kind of professional license or certicate of any kind do you hold in New Jersey, any other
state, the District of Columbia or in any other jurisdiction?
License type: __________________________ License Number:_____________________
Original issue date: ______________ State or jurisdiction that issued the license or certicate:____________
2. Does your license or certication allow you to supervise in the State in which you are licensed?
☐ Yes ☐ No
If “Yes,” provide a copy of the State law or regulation that allows you to supervise along with a copy
of the necessary credentials per that State law or regulation.
III. SupervisionInformation
1. Where will client contact and supervision take place? If different addresses, identify each, use
additional sheets if necessary:
_______________________________________________________________________________
Business Name
_______________________________________________________________________________
Address City State Zip Code
2. Will supervised experience be accrued at multiple locations? ☐ Yes ☐ No
(If “Yes,” include a separate list of site names and addresses, a separate plan of supervision must
be submitted if being supervised by more than one supervisor)
3. Is the supervisor employed by the agency or business where the supervised experience will be
taking place? ☐ Yes ☐ No
If “No,” please attach written consent of the employer to arrange for off-premises supervision
(see N.J.A.C. 13:44G-8.1 (i)).
4. Is there any circumstance that precludes your objective assessment of the applicant?
☐ Yes ☐ No
If “Yes,” please explain on a separate sheet of paper.
5. What are the inclusive dates of supervision? Beginning: ________ Anticipated Ending: ________
Month/day/year Month/day/year
6. Do you agree to maintain weekly supervision notes and co-sign a client contact log which shall
be made available to the Board upon request? ☐ Yes ☐ No
7. Has the applicant read the statutes and regulations of New Jersey that govern the practice of
social work? (N.J.S.A. 45:15BB-1-13 et seq. and N.J.A.C. 13:44G-1.1 through 14.1)
☐ Yes ☐ No
8. Has the supervisor read the pertinent statutes and regulations of New Jersey?
☐ Yes ☐ No
9. What are the personal learning objectives for the supervisee?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
10. Identify the primaryclinicalduties the supervisee will have:
____________________________________________________________________________
____________________________________________________________________________
11. Are these duties enumerated in their job description? ☐ Yes ☐ No
a. If “No,” how is the supervisee performing clinical duties while under your supervision?
________________________________________________________________________
________________________________________________________________________
12. To your knowledge, will the supervisee have more than one supervisor in the above or another
setting during the inclusive dates? ☐ Yes ☐ No
If “Yes,” please advise the supervisee to request that a separate form be submitted by that
supervisor.
ThesupervisorisrequiredtonotifytheBoardofSocialWorkExaminersinwritingofanychanges
intheemploymentofeithertheapplicantorthesupervisorwithin30days.
Certication
I certify that all of the foregoing information provided herein is true and if any information provided by
me is willfully false, I am subject to punishment.
Supervisor’s signature: ________________________________________ Date: __________________
Supervisee’s signature: ________________________________________ Date: __________________
IV. Attachments
Please include the following attachments:
a. Supervisee’s ofcial job description on agency letterhead (the job description should reect
duties that conform to the denition of “clinical social work services” in N.J.A.C. 13:44G-1.2).
b. Supervisor’s resume or curriculum vitae (include academic, licensure, and certication
information).
c. Supervisor’s copy of supervisory credential (20 continuing education credits of post-graduate
course-work related to clinical supervision pursuant to N.J.A.C. 13:44G-8.1 (b)(3)(ii)).
d. If the supervision is being rendered in an agency setting by a supervisor who is not employed
by the agency, a letter from the employer on letterhead consenting to outside supervision (see
N.J.A.C. 13:44G-8.1 (i)).
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Proposed Plan of Supervised Clinical Experience (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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