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 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:*

Fieldwork End Date:*

Are all of these dates being contested?*

Yes

No

Contested Fieldwork Start Date:*

Contested Fieldwork End Date:*

# Independent Contested Hours:*

# Supervised Contested Hours:*

Total Contested Hours:

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.

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.