Bacb Fieldwork And Practicum Experience Supervision Form

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BACB Fieldwork and Practicum Experience Supervision Form
Supervisee:_____________________________
Supervisor:___________________________
Date:__________________________________
Time Start:____________ End:___________
This supervision session addresses the period from ____/____/____ to ____/____/____
During this period, the supervisee accrued _________ hours of experience that met the BACB’s
Experience Standards
Check appropriate characteristics of this supervision period. (check all that apply)
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 supervision 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 & Strategies
__ 4: Behavioral Assessment
__ 9: Behavior Change Procedures
__ 5: Experimental Evaluation of Interventions
__ 10: Systems Support
Check measures of professional integrity.
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
S – satisfactory
NI - needs improvement
U - unsatisfactory
N/A – not applicable
Overall evaluation of supervisee performance during this period (circle one): S NI
U
Supervisee signature: _________________________
Supervisor signature: _______________________
DO NOT SUBMIT THIS FORM TO THE BACB WITH YOUR INITIAL EXAM APPLICATION

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