Trainaba - BCBA Experience Supervision Form (copyright BACB. Visit BACB.com for More Info.) Checklist
Complete this form or equivalent at least once during each 2-week supervisory period. This form was created for the TrainABA Supervision Curriculum books at www.trainaba.com and was not created by the BACB. TrainABA is a BACB-approved continuing education provider and is not endorsed by or affiliated with the BACB. BCBA is copyrighted by BACB. VIsit www.bacb.com for more information. V1.1.5
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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.
What kind of supervised experience did you provide?
Supervisory meeting date
Supervision meeting duration
Additional supervisory meeting date (if applicable)
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)
A. Number of independent experience hours accumulated (excluding time spent with supervisor - use whole number)
B. Number of individual supervision hours accumulated
C. Number of small-group supervision hours accumulated
D. Total experience hours accumulated (add lines A through C)
Of the hours listed above, state the number spent in direct implementation of behavioral programs (hint: must be 50% or less)
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
Arrives on time for supervision
Maintains professional and courteous interactions with clients and consumers
Maintains professional and courteous interactions with other service providers
Maintains professional and courteous interactions with coworkers
Maintains appropriate attire & demeanor
Initiates professional self-improvement
Accepts supervisory feedback appropriately
Seeks supervision appropriately
Timely submission of written reports
Communicates effectively (written)
Communicates effectively (oral)
Demonstrates appropriate sensitivity to non behavioral providers
Supervisee self-detects personal limitations
Supervisee self-detects professional limitations
Acquisition of target behavior-analytic skills
Add photograph of paper supervision form of applicable
Supervisee signature: I attest the above documentation is true and correct to the best of my knowledge.
Supervisor signature: I attest the above documentation is true and correct to the best of my knowledge.
Ben Theisen
TrainABA - BCBA Experience Supervision Form (Copyright BACB. Visit BACB.com for more info.)
Complete this form or equivalent at least once during each 2-week supervisory period. This form was created for the TrainABA Supervision Curriculum books at www.trainaba.com and was not created by the BACB. TrainABA is a BACB-approved continuing education provider and is not endorsed by or affiliated with the BACB. BCBA is copyrighted by BACB. VIsit www.bacb.com for more information. V1.1.5
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to
take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or
treatment;
or other applicable laws. You should also seek your own professional advice to determine if the use of such
checklist is
permissible in your workplace or jurisdiction.
