CONTESTED 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 Fieldwork Information

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:*

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

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.

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 fieldwork form.

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.*

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

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 fieldwork hours?*

Yes
No

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

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

4. Do you have a signed supervision contract?*

Yes
No

Upload your signed supervision contract.*

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

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

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)*

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

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

Acknowledgement

Please note: In addition to the documentation submitted in this form, the BACB may also request that you submit your documentation system and an audit log (see the Documentation Requirements and 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.

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