Monthly Fieldwork Verification Form: Individual Supervisor

Behavior Analyst Certiﬁcation Board | Individual Monthly Fieldwork Veriﬁcation Form

MONTHLY | FIELDWORK VERIFICATION FORM

INDIVIDUAL SUPERVISOR

2022 Fieldwork Requirements

Warning: Forms with missing information will be denied.

You may complete this form in Adobe Acrobat Reader on your

desktop, but not in a web browser. This form contains dropdown

menus that only work in Adobe Acrobat. Alternatively, If you

prefer to print and manually ﬁll out the form, please write your

answers over the dropdown options. If you attempt to complete

this form in a web browser, the dates will not save correctly.

Instructions: Please complete one form per supervisor, per ﬁeldwork type.

Complete this form in its entirety for consideration. Incomplete documents

will not be accepted. The M-FVF must be signed by the last day of the calendar month following the month of supervision.

Both parties must retain a copy of this form for at least 7 years. Do not submit this form to the BACB unless requested.

Trainee Name:

BACB ID #: Month/Year:

Fieldwork Type (Select One):  Supervised Fieldwork  Concentrated Supervised Fieldwork

State Where Fieldwork Occurred:

Country Where Fieldwork Occurred:

Supervisor Name:

Certiﬁcation # or BACB ID #:

Fieldwork Hours (this month only)

A. Independent Hours (supervisor not present):

B. Supervised Hours (supervisor present):

This ﬁeldwork included prorated hours for a partial month.

Supervisor and Trainee Attestation

By signing below, we hereby attest that:

⊲ The information contained on this form is true and correct to the best of our knowledge;

⊲ The required number of supervisory contacts occurred during this month;

⊲ Observation of the trainee with a client occurred during this supervisory period with a frequency appropriate for

this ﬁeldwork type;

⊲ The trainee was supervised for the required amount of time for this supervisory period;

⊲ We have read and understand the most recent version of the Fieldwork Requirements (BCBA/BCaBA)

⊲ We are only including appropriate behavior-analytic activities in our totals listed above; and

⊲ The ﬁeldwork hours obtained during this supervisory period are otherwise compliant with the Fieldwork

Requirements (BCBA/BCaBA)

Supervisor Signature: Date:

Trainee Signature: Date:

Total Fieldwork Hours

(add A & B):

Percent of Hours Supervised

(supervised/total):

This document must be signed in accordance with the Acceptable Signatures Policy.

0.00

0.00%