CONTESTED EXPERIENCE/FIELDWORK FORM – Behavior Analyst Certification Board

Trainee Information

Name:*

First Last

BACB ID:*

Email:

Supervisor Information

Name:*

First Last

BACB ID:*

Qualification Type:*

BCBA-D
BCBA
VCS Verified Instructor
ABPP/ABA

Contested Experience Information

Are you contesting related to the current Experience Standards or the 2022 Fieldwork Standards?*

Current Experience Standards
2022 Fieldwork Standards

Type of Experience:*

Supervised Independent Fieldwork
Practicum
Intensive Practicum

Type of Fieldwork:*

Supervised Fieldwork
Concentrated Supervised Fieldwork

Experience Format*

Multiple Supervisors at One Organization
Individual Supervisor

Fieldwork Format*

Multiple Supervisors at One Organization
Individual Supervisor

Experience Start Date:*

Fieldwork Start Date:*

Experience End Date:*

Fieldwork End Date:*

Are all of these dates being contested?*

Yes
No

Are all of these dates being contested?*

Yes
No

Contested Experience Start Date:*

Contested Fieldwork Start Date:*

Contested Experience End Date:*

Contested Fieldwork End Date:*

Number of Independent Contested Hours:*

Number of Supervised Contested Hours:

Total Number of Contested Hours:*

1. Have you addressed this directly with the supervisor (see 7.02)?*

Yes
No

1. Have you addressed this directly with the supervisor (see 7.02)?*

Yes
No

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

Drop files here or

Files allowed: jpg, png, pdf, doc, docx Maximum total file size: 10MB

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

Drop files here or

Files allowed: jpg, png, pdf, doc, docx Maximum total file size: 10MB

Contact the supervisor and attempt to resolve the issue with them directly before submitting a contested experience form.

Contact the supervisor and attempt to resolve the issue with them directly before submitting a contested fieldwork form.

2. Do you have signed supervision forms from each supervisor period (e.g., BACB Experience Supervision Form, Monthly Experience Verification Form)*

Yes
No

2. Do you have signed supervision forms from each supervisor period (e.g., BACB Monthly Fieldwork Verification Form)*

Yes
No

Upload your signed supervision forms in a single PDF.*

Without a signed Monthly Experience Verification Form or signed supervision forms, we will not process any experience hours.

3. Are you currently in litigation with the supervisor regarding your experience hours?*

Yes
No

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

Yes
No

Upload an overview of the complaint in a single document.*

4. Do you have a signed supervision contract?*

Yes
No

4. Do you have a signed supervision contract?*

Yes
No

Upload your signed supervision contract.*

Does the supervision contract include specific language regarding when the supervisor will not sign the supervision forms or the Experience Verification Form?*

Yes
No

Does the supervision contract include specific language regarding when the supervisor will not sign the supervision forms or the Fieldwork Verification Form?*

Yes
No

Were the supervision forms not signed in accordance with the supervision contract?*

Yes
No

Were the supervision forms not signed in accordance with the supervision contract?*

Yes
No

Because you indicated that the supervision forms were not signed in accordance with the contract, you may not submit a contested experience form because there was not a breach of the supervision contract.

Please note, even though you stated ‘no’, we will be contacting your supervisor to verify.

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

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

Acknowledgment*

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.

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