BCBA Fieldwork Checklist
Complete this checklist to document and verify your supervised BCBA fieldwork experience.
Candidate Full Name
*
First Name
Last Name
Candidate Email Address
*
example@example.com
Supervisor Full Name
*
First Name
Last Name
Supervisor Email Address
*
example@example.com
Type of Fieldwork
*
Supervised Fieldwork
Concentrated Supervised Fieldwork
Fieldwork Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Fieldwork End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Total Number of Fieldwork Hours Completed
*
Percentage of Hours Supervised
*
Types of Activities Completed
*
Direct Implementation of Behavior-Analytic Programs
Assessment
Behavior-Change Procedures
Data Collection and Analysis
Supervision/Training
Other
Supervision Activities (Select all that apply)
*
Individual Supervision
Group Supervision
Real-Time Observation
Feedback and Discussion
Review of Written Materials
Other
Were all fieldwork requirements and supervision standards met?
*
Yes
No
Comments or Additional Notes
Supervisor Signature (to verify fieldwork completion)
*
Submit Checklist
Submit Checklist
Should be Empty: