CONTESTED FIELDWORK FORM - Behavior Analyst Certification Board

The Contested Fieldwork form may be completed when a supervisor refuses or is unable to sign the Final Fieldwork Verification Form, even though all supervision contract terms have been met. This form may only be used to contest signatures on the Final Fieldwork Verification Form and should not be used to contest signatures on Monthly Fieldwork Verification forms or to appeal a determination made by BACB staff.

If you are seeking guidance on how to handle a dispute regarding Final Fieldwork Verification Form signatures, please see the Disputes About Fieldwork Verification Form Signatures document.

Before completing this form, you should:

1. 1. Attempt to resolve the matter with your supervisor(s). In the event that the issue is not resolved, retain documentation of your attempt to include with your submission.
  2. Review the terms of your supervision contract.
  3. Collect any signed Monthly Fieldwork Verification forms that you have for the period in question, along with any documentation that provides evidence that supervision took place.
  4. Determine if there was an ethical violation related to fieldwork which may be reported by filing a Notice of Alleged Violation (NAV).
  5. Determine if this is a matter of a contractual dispute that may need to be addressed through an independent legal process.

"*" indicates required fields

1Introduction

2Trainee

3Supervisor

4Contested FW

5Details

6Attestation

The Contested Fieldwork form may be completed when a supervisor refuses or is unable to sign the Final Fieldwork Verification Form, even though all supervision contract terms have been met. This form may only be used to contest signature of the Final Fieldwork Verification Form and should not be used to contest signature of Monthly Fieldwork Verification forms or to appeal a determination made by BACB staff. Information provided in the form may be shared with the supervisor(s) for verification purposes.

If you are a supervisor seeking guidance on how to handle a dispute with your trainee regarding signing their Final Fieldwork Verification Form, please refer to "Experience/Fieldwork Verification Forms: Preventing Disputes Between Supervisors and Trainees" on p. 1 of the August 2019 BACB Newsletter.

Before completing this form, you should:

Attempt to resolve the matter with your supervisor(s). In the event that the issue is not resolved, retain documentation of your attempt to include with your submission. Please allow at least 15 days for your supervisor to respond before completing this form.
Review the terms of your supervision contract.
Collect any signed Monthly Fieldwork Verification forms that you have for the period in question, along with any documentation that provides evidence that supervision took place.
Determine if there was an ethical violation related to fieldwork which may be reported by filing a Notice of Alleged Violation (NAV).
Determine if this is a matter of a contractual dispute that may need to be addressed through an independent legal process.

Once this form is completed:

You will receive a confirmation that your form has been received, however; we are unable to attest to when you will receive a determination
We will contact your supervisor for verification purposes, and
Conduct a thorough review, including a Fieldwork Audit (see the Audits section of the relevant Handbook)
Once a determination has made, you and your supervisor will be emailed a determination, and
A note will be placed on your record for current or future applications

Trainee's Full Name*

Please use the name you use within your BACB Account.

First Last

Trainee's BACB ID*

This number is located in your BACB Account. This is not your Certification Number. It is the specific ID associated with your account.

Trainee's Email Address*

Please use the email address you use within your BACB Account. If you no longer have access to the email address associated with your BACB account, please use an email address you have access to and be prepared to answer identity verification questions from our team.

Enter Email Confirm Email

Supervisor's Full Name*

First Last

Supervisor's BACB ID*

Qualification Type:*

BCBA-D

BCBA

VCS Verified Instructor

ABPP/ABA

Type of Fieldwork:*

Supervised Fieldwork

Concentrated Supervised Fieldwork

Fieldwork Format*

Multiple Supervisors at One Organization

Individual Supervisor

Fieldwork Start Date:*

MM slash DD slash YYYY

Fieldwork End Date:*

MM slash DD slash YYYY

Are all of these dates being contested?*

Yes

Contested Fieldwork Start Date:*

MM slash DD slash YYYY

Contested Fieldwork End Date:*

MM slash DD slash YYYY

# Independent Contested Hours:*

# Supervised Contested Hours:*

Total Contested Hours:

Provide a brief statement describing the situation you are contesting.*

1. Have you addressed this issue directly with the supervisor and given them at least 15 days to respond?*

Yes

Upload evidence that this has been addressed with the supervisor (e.g., email correspondence).*

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Please contact your supervisor, if you have not already done so, and allow them 15 days to communicate with you,

2. Are you currently in litigation with the supervisor regarding your fieldwork hours? **

Yes

The BACB cannot review your contested fieldwork at this time, please submit a form when a resolution has been reached.

3. Do you have Monthly Fieldwork Verification Forms signed by both you and your supervisor for the months within the contested fieldwork time period?*

Yes

Upload your signed Monthly Fieldwork Verification Forms in a single PDF.*

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 1.

Without Monthly Fieldwork Verification Form(s) signed by both you and your supervisor we cannot review your contested fieldwork.

4. Do you have a documentation system to support the hours being contested? (see Documenting Fieldwork section of the relevant Handbook)*

Yes

Upload your documentation system.*

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 1.

Without a documentation system to verify and support the hours being contested we cannot review your contested fieldwork.

5. Do you have a signed supervision contract?*

Yes

Upload your signed supervision contract.*

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 1.

Describe the language in your contract specifying when the supervisor will and will not sign the Final Fieldwork Verification Form and specify the page number within the contract.

Upload evidence that supervision contract was never provided (e.g., email correspondence).*

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 1.

Note: In addition to the documents submitted in this form the BACB may also request additional fieldwork documentation (see the Audits section of the BCaBA or BCBA Handbook).

Attestation*

By submitting this form, I confirm that all of the information provided is true and accurate to the best of my ability. I understand that I may also submit a Notice of Alleged Violation if I believe that a certificant has violated the Professional and Ethical Compliance Code for Behavior Analysts.