OSBLSW Form 202 Revised 12/2013 Page 1 of 1
SOCIAL WORK EDUCATIONAL SUPERVISION LOG
SUPERVISEE
SUPERVISOR
Date of
Supervision
Individual
Supervision
Hours
Group
Supervision
Hours
Total
Work
Hours
Total
Clinical
Hours
Date of
Supervision
Individual
Supervision
Hours
Group
Supervision
Hours
Total
Work
Hours
Total
Clinical
Hours
(This form must accompany each set of supervision evaluation forms (i.e. 6 mo/12 mo/24 mo/Partial)
Total number of Individual Educational (face-to-face) Supervision hours this evaluation:
Total number of Group Educational Supervision hours this evaluation:
Total Hours of Practice/Work Under Supervision this evaluation:
Total Hours of Direct Clinical Hours this evaluation:
Evaluation 1
Evaluation 2 Evaluation 3
PARTIAL SUPERVISION: FROM ____________________ TO __________________
Signature of Supervisee Date Signature of Supervisor Date
For the Individual Supervision Hours, Group Supervision Hours, Total Work Hours and Total Clinical Hours, only enter the hours worked for
the time period in between supervision meeting. DO NOT offer an accumulated total from week to week. For example, if you are working a
40 hour work week, and meeting with your supervisor weekly, we should see in the total work hours only the number 40, not 40, 80, 120,
160, etc. Call the Board Office in advance if you have any questions about entering the correct information.
