Bacb Experience Supervision Form

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BACB Fieldwor k and Pr acticum Exper ience Super vision For m
Supervisee:_____________________________
Supervisor:___________________________
Date:__________________________________
Time Start:___________ End:___________
This supervision session addresses the period from ____/____/____ to ____/____/____
Check appr opr iate char acter istics of super vision session. (√ if yes)
Specific
Client
Group
Individual
Office
On-Site
Remote
Video
In Situ
Client(s)
privacy
Supervision
Supervision
Supervision
Supervision
Supervision
Observation
Observation
Discussed
protected
of
of
supervisee
supervisee
Readings suggested by supervisor: _______________________________________________________________
Readings discussed in supervision: _______________________________________________________________
Check BACB task list items discussed in this super vision session.
__ 1: Ethical Considerations
__ 6: Measurement of Behavior
__ 2: Definition and Characteristics
__ 7: Displaying and Interpreting Behavioral Data
__ 3: Principles, Processes, and Concepts
__ 8: Selecting Intervention Outcomes and Strategies
__ 4: Behavioral Assessment
__ 9: Behavior Change Procedures
__ 5: Experimental Evaluation of Interventions
__ 10: Systems Support
Check measur es of pr ofessional integrity.
S – satisfactory
NI - needs improvement
U - unsatisfactory
N/A – not applicable
S
NI
U
N/A
Arriving on time for supervision
Maintains professional and courteous interactions with:
Clients/Consumers
Other Colleagues
Other Service Providers
Coworkers
Maintains appropriate attire & demeanor
Initiates professional self-improvement
Accepts supervisory feedback appropriately
Seeks supervision appropriately
Timely submission of written reports
Communicates effectively
Written
Oral
Demonstrates appropriate sensitivity to non-behavioral providers
Supervisee self-detects personal limitations
Supervisee self-detects professional limitations
Over all evaluation of super visee per for mance dur ing this per iod (cir cle one): S NI
U
Supervisee signature
Supervisor signature
: ____________________________
: __________________________

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