Title Page
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BACB Supervised Experience Form
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Supervisor name
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BCBA-exam Candidate name
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Beginning of supervisory period covered in this form
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End of supervisory period covered in this form
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Prepared by
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Location
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Document number (optional)
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I understand these templates are provided by TrainABA to the ABA community for educational purposes as part of the supervision curriculum books at www.trainaba.com. Use of these templates does not constitute or imply proof of satisfactory supervision toward BACB credential requirements or regulations as applicable to user's country, state/province, city, funding source, work environment, or company policy. RBT and BCBA credentials are copyright of the BACB. This form was not created, distributed, or maintained by the BACB.
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What kind of supervised experience did you provide?
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Supervisory meeting date
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Additional supervisory meeting date (if applicable)
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Supervisory meeting formats delivered in this supervisory period (check all that apply)
- Individual
- Group (10 or less)
Experience Hours Accumulated During This Supervisory Period (complete all four lines)
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Characteristics of Supervision Conducted During This Supervisory Period (check all that apply)
- BACB task list skills covered (list task numbers as comment on mobile)
- Specific client(s) discussed
- Client privacy protected
- Observation of supervisee (video)
- Observation of supervisee (in-person)
- Supervisory discussion & feedback (in-person)
- Supervisory discussion & feedback (remote)
- Readings (add comment)
Evaluation of Supervisee Performance
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Arrives on time for supervision
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Maintains professional and courteous interactions with clients and consumers
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Maintains professional and courteous interactions with other service providers
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Maintains professional and courteous interactions with coworkers
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Maintains appropriate attire & demeanor
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Initiates professional self-improvement
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Accepts supervisory feedback appropriately
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Seeks supervision appropriately
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Timely submission of written reports
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Communicates effectively (written)
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Communicates effectively (oral)
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Demonstrates appropriate sensitivity to non behavioral providers
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Supervisee self-detects personal limitations
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Supervisee self-detects professional limitations
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Acquisition of target behavior-analytic skills
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Add photograph of paper supervision form of applicable
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Supervisee signature: I attest the above documentation is true and correct to the best of my knowledge.
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Supervisor signature: I attest the above documentation is true and correct to the best of my knowledge.
