Pa Doc 3 Psychological - Associate Applicant Program Verification Form - North Carolina Psychology Board Page 2
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27. Did the program encompass the equivalent of one academic year of full-time graduate study in student residence at
the institution from which the degree was granted? [Residence requires interaction with psychology faculty and other
matriculated psychology students at the institution, and is defined as 30 semester (45 quarter or 40 trimester) hours
taken on a full-time or part-time basis at the institution.]
Yes
No
8. Did the program include internship, externship, practicum, or other field experiences appropriate to the area of
specialty and the practice of psychology which was supervised by a psychologist?
Yes
No
Was the supervised training experience completed within a period of 12 consecutive months at not more than two
training sites?
Yes
No
Provide the following:
Training Site Name
Training site Director
Dates
Was this supervised training planned by the educational program’s faculty and training site staff?
Yes
No
9. Did the program of study include a minimum of 45 semester (68 quarter or 60 trimester) hours of graduate study in
standard psychology courses, crediting not more than 6 semester (9 quarter or 8 trimester) hours for internship/
practicum and not more than 6 semester (9 quarter or 8 trimester) hours for thesis/dissertation?
Yes
No
Did the program include courses drawn from academic psychology, statistics and research design, scientific and
professional ethics and standards, and a specialty area?
Yes
No
Speciality Area: ____________________________________
AFFIDAVIT: I certify that I have personal knowledge of the program evaluated above, in which the applicant received
his/her master’s/specialist degree and that all answers marked on this form and any other information attached hereto are
true and correct to the best of my knowledge.
Typed/printed name and title of person completing Part 2:
Name _________________________________________________ Title _________________________________
Department: _________________________________________________________________________________
University: __________________________________________________________________________________
Address: ____________________________________________________________________________________
Telephone Number:_______________________
E-mail Address: ______________________________
Signature: ________________________________________________
Sworn to (or affirmed) and subscribed before me this _________ day of _____________________, 20____.
_________________________________________________________
Notary’s Signature
My Commission Expires _________________________________, 20 ____.
SEAL
Page 2 of 2
PADOC#3 09/09
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