Pa Doc 3 Psychological - Associate Applicant Program Verification Form - North Carolina Psychology Board
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1
2North Carolina Psychology Board
PA DOC #3
895 State Farm Road, Suite 101, Boone, NC 28607
Telephone: (828) 262-2258
PSYCHOLOGICAL ASSOCIATE APPLICANT
PROGRAM VERIFICATION FORM
(type or print all information)
PART 1. This part is to be completed by the applicant for licensure in North Carolina.
Your Name: ________________________________________________________________________________
Name of institution from which master’s/specialist degree was awarded: ________________________________
Date master’s/specialist degree was awarded: ______________________________________________________
Department Name (when degree was awarded): ____________________________________________________
PART 2. This part is to be completed by the Head of the program from which the applicant was awarded his/her
master’s/specialist degree. After completion, the form must be mailed DIRECTLY to the Board at the above address.
In accordance with North Carolina General Statute § 90-270.11(b)(1)c, the Psychology Board has adopted rules and
regulations implementing and defining the statute which requires that a Psychological Associate applicant possess a
master’s or specialist degree in psychology from an institution of higher education. The above named applicant requests
your cooperation in verifying the following components of his/her program. Please respond to the following based
upon the master’s or specialist degree program requirements during the time when the applicant was enrolled.
This form must be completed & signed by the Head of the program only after all degree requirements that are
being verified on this form have been completed by the applicant. ALL items must be completed.
1. Was the program publicly identified and clearly labeled as a psychology program, specifying in pertinent institutional
catalogues its intent to educate and train students to engage in the activities which constitute the practice of
psychology?
[
Yes
No
State the program title: __________________________________
2. Did the program maintain clear authority and primary responsibility for the core and specialty areas whether or not
the program crossed administrative lines?
[
Yes
No
3. Did the program have an identifiable body of students in residence at the institution who were matriculated in the
program for a degree?
[
Yes
No
4. Was there an identifiable full-time psychology faculty in residence at the institution, employed by and providing
instruction at the home campus of the institution?
[
Yes
No
State the number of full-time psychology faculty in residence at the institution: __________
5. Was there a psychologist responsible for the student’s program either as the administrative head of the program, or
as the advisor, major professor, or committee chair for the individual student’s program?
[
Yes
No
If Yes, provide the psychologist’s name and title or role: ________________________________________
6. Was the program an integrated, organized sequence of study as demonstrated by an identifiable curriculum track or
tracks wherein course sequences were outlined in institutional catalogues, departmental handbooks, or other
institutional publications?
[ Yes
No
Pa ge 1 of 2
PADOC#3 09/09
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