Blank Supervision Hours Form PDF Details

A blank supervision hours form is an important document for any organization. This document helps to track the amount of time employees spend under the direct supervision of their supervisor. The form can be used to monitor employee productivity and ensure that all workplace policies and procedures are being followed. In addition, the form can also be used as a basis for OHS training records. Supervision hour forms are typically created by organizations following a set template. The form will list the name of the supervisor, as well as the department or work area where the employee is situated. It is important to include all pertinent information on this form in order to accurately track employee hours. Any discrepancies discovered through reviewing this document can help organizations improve their overall workforce productivity.

You can find information about the type of form you would like to complete in the table. It can show you the time you will require to finish bla

QuestionAnswer
Form NameBlank Supervision Hours Form
Form Length4 pages
Fillable?Yes
Fillable fields1
Avg. time to fill out1 min 12 sec
Other namesImplement, bcba supervision hours tracking form, BCBA, Fieldwork

Form Preview Example

The University of the State of New York

 

 

 

 

Social Worker Form 6

The State Education Department

 

 

 

 

 

 

 

 

 

Office of the Professions

 

 

Plan for Supervised Experience

www.op.nysed.gov

 

 

Division of Professional Licensing Services

 

 

 

 

 

 

 

 

 

 

 

Application for Licensed Master Social Worker

 

 

 

 

73

$10

MI

 

A Licensed Master Social Worker (LMSW) must be registered to practice in New York State and may only provide clinical social work services, including psychotherapy, under the supervision of a Licensed Clinical Social Worker (LCSW), licensed psychologist or licensed physician who is board-certified in psychiatry in an authorized setting, as defined in Education Law and Commissioner's Regulations. The setting is responsible for employing the LMSW and the qualified supervisor to provide clinical social work services; a LMSW cannot employ or contract with a supervisor.

Prior to starting your supervised experience, you can verify the license status of your proposed supervisor on the Office of the Professions' web site at www.op.nysed.gov/opsearches.htm. This form must be submitted prior to being employed or supervised by your proposed supervisor. This form will not be reviewed if submitted after the supervised experience has been completed.

Applicant Instructions

1.Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensure (FOrm 1). Be sure to sign and date item 9. Use the psychotherapy log to document your hours of practice and supervision.

2.Send the entire form along with a copy of Appendix A to your supervisor and have them complete Section II. Return all pages along with the $10 fee directly to the Office of the Professions at the address at the end of this form.

Section I: Applicant Information

1. Social Security Number

(Leave this blank if you do not have a U.S. Social Security Number)

2. Birth Date

Month

Day

Year

3. Print Name

Last

 

First

 

Middle

Licensee business address, phone and email address are public information. Failure to indicate business or home on this form for each item will deem it public information.

4.Mailing Address Home or Business

(You must notify the Department within 30 days of any address or name changes)

Line 1

Line 2

Line 3

City

State

 

 

ZIP Code

Country/

Province

5.Telephone/Email Address Daytime Phone

Home or Business

Area Code

Phone

Email Address (please print clearly)

Home or Business

6.New York State DMV ID Number (Driver or Non-Driver ID)

(Leave this blank if you do not have a New York State DMV ID Number)

7. New York State LMSW license number

Date LMSW license issued

mo. day yr.

M.S.W. degree date

mo. day

yr.

Date registration ends

mo. day

yr.

8.You must complete 2,000 client contact hours of post-MSW supervised experience in diagnosis, psychotherapy and assessment-based treatment plans over a period of at least 36 months and no more than 6 years. You must be supervised by a licensed clinical social worker, licensed psychologist or physician who meets the requirements of section 74.6 of the Commissioner’s Regulations in an acceptable setting as defined in section 74.6.

Name of proposed supervisor

Name of setting

Setting address

9.I declare and affirm that the statements made in the foregoing application, including accompanying statements are true, complete and correct. I understand that any false or misleading information in, or in connection with my application may be cause for denial of licensure and may lead to a filing of charges of professional misconduct.

Signature

Date

Social Worker Form 6, Page 1 of 2, Revised 11/21

Section II: Supervisor's Verification of Plan for Experience

Instructions to the Supervisor: Read the attached Appendix A and complete all of Section II. Be sure to sign the affidavit and return the entire form directly to the Applicant. By completing Section II, you are certifying that the person named in Section I will receive supervision that meets the requirements as defined in Education Law and the Commissioner's Regulations.

1.Name of the applicant

(see Section I, item 3)

2.Supervisor name

I am licensed and currently registered to practice in New York State as a (check all that apply)

Licensed Clinical Social Worker

Licensed Psychologist

Licensed Physician

Are you ABPN certified in psychiatry?

 

 

 

License number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

License number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

License number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No If "yes", ABPN certificate number

 

 

License date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo.

 

day

yr.

License date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo.

 

 

 

 

day

 

 

 

yr.

License date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo.

 

 

 

day

 

 

 

yr.

3.Please identify the employment setting below and attach the operating certificate, NYSED waiver or certificate of incorporation that authorizes the entity to employ LMSWs and LCSWs.

Agency/Practice Name

Type of Setting (check one)

Private practice owned by supervisor (LCSW, Licensed psychologist or psychiatrist)

Professional entity (PLLC, PLLP, P.C.) owned by supervisor (attached consent from SED)

Sole proprietorship or other entity authorized under law (attach certificate of corporation)

Program approved by the New York State Office of Mental Health (OMH), Office for People with Developmental Disabilities (OPWDD),Office of Alcoholism & Substance Abuse Services (OASAS), Office of Children & Family Services (OCFS), Department of Corrections and Community Supervision (DOCCS), Department of Health (DOH), State Office for the Aging, or local social service or mental hygiene district (attach operating certificate)

Elementary, middle, high school or college authorized to provide psychotherapy services to students (attach copy of authorization)

Psychotherapy institute chartered by Board of Regents and authorized to provide psychotherapy to the public (attach copy of Regents Charter)

Not-for-profit or other entity authorized by waiver from the State Education Department to employ licensed professionals and provide services (attach waiver and certificate of incorporation)

Other (describe)

Agency/Practice address

 

 

 

 

 

 

Agency/Practice Phone

 

 

 

 

 

 

 

Fax

 

Email

 

 

 

 

 

 

 

 

Agency/Practice web site

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The supervisor must be employed by the same agency as the LMSW and have access to all patient files and records; have responsibility for the assessment, evaluation and treatment of each patient diagnosed and treated by the LMSW practicing under his/her supervision; and each patient must consent to treatment by the supervised LMSW.

Attestation

I hereby certify that I have read Appendix A and that I meet the requirements to supervise a LMSW practicing clinical social work. I understand that the information above will be used to review the plan, all answers given are truthful and accurate to the best of my ability.

Supervisor Signature

 

 

 

Date

Print Name

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone

Fax

 

 

 

 

 

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

If you are submitting an initial Form 6, mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY 12201, U.S.A.. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.

Social Worker Form 6, Page 2 of 2, Revised 11/21

Appendix A, Requirements for Supervised Experience LMSW

You must document the completion of three years of post-graduate full-time supervised clinical social work experience in diagnosis, psychotherapy, and assessment-based treatment plans, or the part-time equivalent, or combination of full-time and part-time supervised clinical social work in no more than six consecutive years.

Experience shall consist of not less than 2,000 client contact hours over the course of three years but not to exceed six calendar years. All experience must be obtained in a setting acceptable to the Department after completion of the professional education required for licensure.

Qualified Supervisor

The experience must be supervised by a professional who is licensed and registered to practice as a(n):

LCSW in New York State or the equivalent as determined by the Department; or

Psychologist who, at the time of supervision of the applicant, was licensed as a psychologist in the state where supervision occurred, was qualified in psychotherapy as determined by the Department based upon the Department's review of the psychologist's education and training, including but not limited to education and training in psychotherapy obtained through completion of a program in psychotherapy registered pursuant to Part 52 of the Regulations of the Commissioner of Education or a program in psychology accredited by the American Psychological Association; or

Physician who, at the time of supervision of the applicant, was a diplomate in psychiatry of the American Board of Psychiatry and Neurology, Inc. or had the equivalent training and experience as determined by the Department.

A supervisor who is not licensed in New York State must submit an Approval of Qualifications to Supervise Psychotherapy (Form 4Q) to allow the Department to determine whether the supervisor is qualified in diagnosis, psychotherapy and assessment-based treatment planning.

A supervisor may not have a familial relationship with the applicant, as such dual relationships may constitute a charge of unprofessional conduct under the Education Law and Regents Rules.

Supervision Sessions

The supervision must consist of 100 or more hours of in-person individual or group clinical supervision distributed over the period of the supervised experience. During each supervision session:

your supervisor must provide the diagnosis and appropriate treatment for each client;

your cases must be discussed with your supervisor; and

your supervisor must provide you with oversight and guidance in diagnosis and treating clients.

The supervisor is legally and professionally responsible for the diagnosis and treatment of each client and must have access to all relevant information. It is the responsibility of your employer to provide appropriate supervision as an LMSW may only practice clinical social work under supervision. Any arrangements for third-party supervision must include a written agreement between the employer, third-party supervisor and the LMSW to specify the supervisor's access to clients and client records to ensure appropriate supervision of the LMSW. The client must be informed of how confidential information is handled in the case of third-party supervision and how to raise questions with the employer and/or third-party supervisor.

Setting for the Experience

All experience that is completed in New York State must be in a setting that is legally authorized to provide psychotherapy and clinical social work services. An acceptable setting is:

A professional corporation, professional limited liability partnership or professional limited liability corporation that is authorized to provide services that include psychotherapy;

A professional service corporation, registered limited liability partnership, or professional service limited liability company authorized to provide services that are within the scope of practice of licensed clinical social work;

A sole proprietorship owned by a licensee who provides services that are within the scope of his or her profession and services that are within the scope of licensed clinical social work;

A program or service approved by the New York State Office of Mental Health (OMH), Office for People with Developmental Disabilities (OPWDD), Office Addiction Services and Supports (OASAS), Office of Children & Family Services (OCFS), Department of Corrections and Community Supervision (DOCCS), Department of Health (DOH), State Office for the Aging, or local social service or mental hygiene district;

A program or facility authorized under federal law, such as the Veterans' Administration, to provide health services including psychotherapy;

A public elementary, middle or high school authorized by the Education Department to provide school social work services as defined in Part 80-2.3 of the Commissioner’s Regulations, including clinical social work;

An entity defined as exempt from the licensing requirements under New York Law* or otherwise authorized under New York Law of the laws of the jurisdiction in which the entity is located to provide services, including psychotherapy.

In New York State, a general business corporation or not-for-profit corporation may not provide professional services or employ licensed professionals unless authorized under law. The certificate of incorporation should clarify the purpose of the entity and whether licensed professionals may be employed to provide services that are restricted under Title VIII of the Education Law.

It is your responsibility to practice only under a qualified supervisor and in an authorized setting. You should review the supervisor qualifications and acceptable experience with an employer before you accept a position practicing clinical social work.

Licensed Master Social Worker Appendix A, Revised 11/21

Psychotherapy Log

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Use this weekly log to document the applicant's hours of practice and supervision for Licensed Clinical Social Work. All pages

 

Page

of this log must be retained by the supervisor and submitted upon request of the Department. Please copy this log as needed.

 

 

 

 

 

 

 

 

 

 

 

 

 

of

Applicant name

Supervisor name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Week starting date for

psychotherapy

(mo./day/yr.)

Client Contact

Hours/Week*

Applicant Initials

Supervision Type

(Individual or Group)**

Supervision

Hours/Week**

Supervisor Initials

*Client contact hour = 45 minutes of psychotherapy (shorter sessions may be combined) **Supervision = at least 100 hours of in person supervision given by the attesting supervisor

Social Worker Psychotherapy Log, Revised 11/21

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bcba supervision hours tracking form empty fields to fill in

You should prepare the Licensee business address, Business, Home or, (You must notify the Department, Line 1, Line 2, Line 3, City, State Country/ Province, ZIP Code, Email Address (please print, Home or, Business, (Driver or Non, Driver ID), and (Leave this blank if you do not box with the required data.

bcba supervision hours tracking form Licensee business address, Business, Home or, (You must notify the Department, Line 1, Line 2, Line 3, City, State Country/ Province, ZIP Code, Email Address (please print, Home or, Business, (Driver or Non-Driver ID), and (Leave this blank if you do not fields to fill out

It is vital to note some details in the section Section II: Supervisor's, (see Section I, I am licensed and currently, Licensed Clinical Social Worker, Licensed Psychologist, Licensed Physician, License number, License number, License number, Are you A, BP, N certified in, Yes, No If "yes", License date, License date, and License date.

bcba supervision hours tracking form Section II: Supervisor's, (see Section I, I am licensed and currently, Licensed Clinical Social Worker, Licensed Psychologist, Licensed Physician, License number, License number, License number, Are you ABPN certified in, Yes, No If

The Private practice owned by, Agency, Practice address, Agency, Practice Phone, Agency, Practice web site, Fax, Email, The supervisor must be employed by, Attestation I hereby certify that, and Date box may be used to indicate the rights and responsibilities of each party.

bcba supervision hours tracking form Private practice owned by, Agency/Practice address, Agency/Practice Phone, Agency/Practice web site, Fax, Email, The supervisor must be employed by, Attestation I hereby certify that, and Date blanks to insert

Fill out the template by looking at the next areas: Telephone Email, Fax, and If you are submitting an initial.

bcba supervision hours tracking form Telephone Email, Fax, and If you are submitting an initial fields to insert

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