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1 BEHAVIOR ANALYST CERTIFICATION BOARD 行为分析分析师师师委员会 - Experience Standards 实践经经规定 - INSTRUCTIONS 规定说明 This document contains all of the standards and forms for experience used to qualify for BACB certification. 对于行为分析师师师委员会 (BACB) 所有师师的规定说明及所需填写的实践经经表单, 都包含在本文件内 All experience used toward the requirements for BACB certification must meet these standards. The BACB requires the supervisor and supervisee review this entire document together and discuss any concerns before the experience begins. BACB 认认要求之所有实践经经, 均需符合以下所列规定 BACB 要求督导和被督和被督导人员在开始累始累计实践经经之前, 必需共同共同审审本文件, 并讨讨协协任何相任何相关之顾顾 In addition to the experience-standards definitions, this document contains two forms for documenting experience used toward BACB certification. They are: 除了说明实践经经规定的定义之外, 本文件另包含两份表单以供记记师师所需之实践经经, 两份表单为 : 1. The Experience Supervision Form: This form, or equivalent, must be completed at least once during each supervision period, throughout the duration of your experience. This form must be duplicated with a copy retained by both the supervisor and supervisee. 实践经经督导表单 : 在整个累计经经期间的每次督导导间内, 这份表单或等量表单填写完成必须至少一次 这份表单必须由督导人和受督导人各持相同的一份 And 以及 2. The Experience Verification Form: This form should be completed at the conclusion of your experience. If you have multiple experiences, you will need to complete multiple forms; one for each experience/supervisor. The original, unaltered form must be submitted. Forms with white-out or other alterations will not be accepted. Forms must bear the supervisor s original signature. Photocopies will not be accepted. All applicants for certification must submit documentation of their experience using the current version of the Experience Verification Form. Previous versions of the form will no longer be accepted. Page 1 of 14

2 实践经经师明表单 : 本表单应在你的实践经经累计计束导填写完成 如果你有多项实践经经, 你需要填写多份表单, 每一份用于每一项实践经经及每一位督导 将未修改之原始表单呈交给本委员会 若表单上有修正液或其他修改痕迹, 将不被接受 表单上须有督导人员的原始签名 填写完复印的表单也不被接受 所有申请师师者必须呈交目前最新版本的实践经经师明表单, 先前的版本不再被接受 Initial exam applications should include Experience Verification Forms only. Do not submit the Experience Supervision Forms completed during each supervisory period unless specifically requested by the BACB. 首次考试申请应只包括实践经经核实表, 除非 BACB 特别要求, 否则不必呈交不必呈交每次督 之实践经经督导表 除非 要求, 否 不必呈交 次督导导导完成 Page 2 of 14

3 EXPERIENCE CATEGORIES 实践经经经经 SUPERVISED INDEPENDENT FIELDWORK (1500 hours BCBA, 1000 hours BCaBA): To qualify under this standard at the BCBA level, supervisees must complete 1500 hours of Supervised Independent Fieldwork in behavior analysis. To qualify under this standard at the BCaBA level, supervisees must complete 1000 hours of Supervised Independent Fieldwork in behavior analysis. A supervisory period is two weeks. In order to count experience hours within any given supervisory period, supervisees must be supervised at least once during that period for no less than 5% of the total hours spent in Supervised Independent Fieldwork. For example, 20 hours of experience would include at least 1 supervised hour. 在督导之下的独立之下的独立实务工作 ( 认认行为分析分析师 BCBA 需 1500 小时, 认认副行副行为分析分析师 BCaBA 需 1000 小时 ): 为符合 BCBA 等级之资格, 受督导人必须完成 1500 小导在督导之下的行为分析独立实实工作 为符合 BCaBA 等级之资格, 受督导人必须完成 1000 小导在督导之下的行为分析独立实实工作 一次督导期间为二星期二星期 在任何一次督导期间内可予计算的实践经经小导是, 受督导人于二星期督导期间内, 必须接受不少于在督导之下独立实实工作总导数之 5% 的至少一次至少一次督导 举例,20 小导的实践经经就要包括至少 1 小导的受督导小导 PRACTICUM (1000 hours BCBA, 670 hours BCaBA): To qualify under this standard at the BCBA level, supervisees must complete, with a passing grade, 1000 hours of Practicum in behavior analysis within a university practicum program approved by the BACB and taken for graduate academic credit. To qualify under this standard at the BCaBA level, supervisees must complete, with a passing grade, 670 hours of Practicum in behavior analysis within a university practicum program approved by the BACB and taken for academic credit. A supervisory period is one week. In order to count experience hours within any given supervisory period, supervisees must be supervised at least once during that period for no less than 7.5% of the total hours spent in Practicum. For example, 20 hours of experience would include at least 1.5 supervised hours. 实实课程 (BCBA1000 小时,BCaBA670 小时 ): 为符合 BCBA 等级之资格, 受督导人必须以及格分数通过并完成 1000 小导行为分析实实实 该实程需为 BACB 核准之大学实实实程核准, 且为为士学程之学分 为符合 BCaBA 等级之资格, 受督导人必须以及格分数通过并完成 670 小导行为分析实实实, 该实程需为 BACB 核准之实实实程, 且为修实之学分 一次督导期间为一星期一星期 在任何一一星期次督导期间内可予计算的经经小导是, 受督导人于一星期督导期间内, 必须接受不少于实实实总导数之 7.5% 的至少一次至少一次督导 举例,20 小导的经经就要包括至少 1.5 小导的受督导小导 至少一次 INTENSIVE PRACTICUM (750 hours BCBA, 500 hours BCaBA): To qualify under this standard at the BCBA level, supervisees must complete, with a passing grade, 750 hours of Intensive Practicum in behavior analysis within a university practicum program approved by the BACB and taken for graduate academic credit. To qualify under this standard at the BCaBA level, supervisees must complete, with a passing grade, 500 hours of Intensive Practicum in behavior analysis within a university practicum program approved by the BACB and taken for academic credit. A supervisory period is one week. In order to count experience hours within any given supervisory period, supervisees must be supervised at least twice during that period for no less than 10% of the total hours spent in Intensive Practicum. For example, 20 hours of experience would include at least 2 supervised hours. Page 3 of 14

4 高密度 高密度实实 (BCBA BCBA750 小时,BCaBA BCaBA 小时 ): 为符合 BCBA 等级资格, 受督导人必须以及格分 数通过并完成 750 小导之行为分析高密度实实, 该实程必须为 BACB 核准之大学实实实程, 且为为士学程之学分 为符合 BCaBA 等级资格, 受督导人必须以及格分数通过, 并完成 500 小导行为分析高密度实实, 该实程需为 BACB 核准之大学实实实程核准, 且为修实之学分 一次督导期间为一星期 在任何一次督导期间内可予计算的实践经经小导是星期, 受督导人于一星期督导期间内, 必须接受不少于高密度实实实总导数之 10% 的至少至少两次督导 举例,20 小导的实践经经就要包括 至少 2 小导的受督导小导 For all three of the above options, no fewer than 10 hours but no more than 30 hours, including supervision, may be accrued per week. Supervisees may accrue experience in only one category per supervisory period (i.e., Supervised Independent Fieldwork, Practicum, or Intensive Practicum). 以上三个选项每周所累计的导数, 包括督导导间在内, 不得少于 10 小导, 不得多于 30 小导 受督导人每一个督一个督导期导只得在一个只得在一个选选中累计实践经经 ( 亦即, 在督导之下的独立实实工 作, 实实实程, 或高密度实实 ) COMBINATION OF EXPERIENCE CATEGORIES: Supervisees may elect to accrue hours in a single category or may combine any 2 or 3 of the categories above (Supervised Independent Fieldwork, Practicum, Intensive Practicum) to meet the experience requirement, with Practicum having 1½ times the temporal value of Supervised Independent Fieldwork, and Intensive Practicum having 2 times the temporal value of Supervised Independent Fieldwork. 合并实践经经经经之 : 受督导人可以选选在单一类类或合并以上两个或三个类类 ( 在督导下的 独立实实工作, 实实实程, 或高密度实实 ) 中累计实践经经, 以达到要求 在计算合并类类导数导, 实实导间可相当于受督导的独立实实工作导间之 1.5 倍, 高密度实实导间可相当于受督导的独立实实工作导间之 2 倍 Page 4 of 14

5 STANDARDS 规定标准 ONSET OF EXPERIENCE: Supervisees may not start accumulating Supervised Independent Fieldwork, Practicum, or Intensive Practicum hours until they have started attending courses required to meet the BACB coursework requirements. 实践经经累计开始 : 受督导人在开始修实 BACB 所需实程之前, 不得开始累计受督导之独立实实工作, 实实或高密度实实 APPROPRIATE ACTIVITIES: The supervisee s primary focus should be acquiring new behavioranalytic skills related to the BACB Third Edition Task List or the BACB Fourth Edition Task List as appropriate. Activities must be consistent with the dimensions of applied behavior analysis identified by Baer, Wolf, and Risley (1968) in the article Some Current Dimensions of Applied Behavior Analysis published in the Journal of Applied Behavior Analysis. The supervisor will determine if experience activities qualify based on these sources. 符合规定的活的活动 : 受督导人的主要注意焦点应为应取新的行新的行为分析技能, 这些技能视恰当情况与 BACB 第三版或与第四版工作表有关 活动必须与三位学者于 1968 年界定的应用行为分析面向一致 三位学者是 Baer, Wolf, 和 Risley, 于 1968 年在 < 应用行为分析期刊 > 发表了文章 应用行为分析当前的一些面向 督導人督導人根据 根据这些来源, 将决定受督导人的活人的活动是否合格 Supervisees are strongly encouraged to have multiple experiences (e.g., sites, populations) with multiple supervisors and from each of the activity areas below. 我们们烈鼓励受督导人在多位督导之下, 拥有多项经经 ( 例如, 不同地点, 不同对象 ), 以及在下列活动动域中, 每一项都能累计实践经经 Conducting assessments related to the need for behavioral intervention (e.g., stimulus preference assessment, functional assessment, staff performance assessment); 进行与行为干预有关的评估 ( 例如刺激偏好评估, 功能评估, 工作人员员效评估 ); Designing, implementing, and systematically monitoring skill-acquisition and behaviorreduction programs; 设计, 实施, 技能采集之系统化监控, 以及行为减少实程 ; Overseeing the implementation of behavior-analytic programs by others; 监督他人的行为分析计划施行情况 ; Training, designing behavioral systems, and performance management; 训训, 设计行为系统, 与员效管理 ; Other activities normally performed by a behavior analyst that are directly related to behavior analysis such as attending planning meetings regarding the behavior analytic program, researching the literature related to the program, and talking to individuals about the program. 其他通常由行为分析师所做, 直接与行为分析相关的活动, 例如参加针对行为分析实程的计划会议, 研究与实程相关的文献, 以及与他人讨讨计划或实程 Examples of activities that will not count as experience include: attending meetings with little or no behavior-analytic content; providing interventions that are not based in behavior analysis; performing nonbehavioral administrative activities; and completing nonbehavioral assessments (e.g., diagnostic Page 5 of 14

6 assessments, intellectual assessments), paperwork, documentation, billing, or any other activities that are not directly related to behavior analysis. 不会被计算为经经的活动举例如下 : 参加不具备或只具备很少行为分析内容的会议 ; 提供并非以行为分析为基础的干预 ; 进行与行为无关的行政活动 ; 和进行与行为无关的评估 ( 例如诊断评估, 智力评估 ); 处理文书, 记记, 作帐, 或其他不直接与行为分析有关的活动 No more than 50% of the total accrued experience hours can be in the direct implementation of behavioral programs. 所累积的经经导数中不可有超过 50% 用在行为实程的直接执行上 APPROPRIATE CLIENTS: Clients may be any persons for whom behavior-analytic services are appropriate. However, the supervisee may not be related to the client or the client s primary caretaker or be the client s primary caretaker. Supervisees must work with multiple clients during the experience period. (Also, see the following relevant sections of the BACB Guidelines for Responsible Conduct for Behavior Analysts: 1.06, 1.07, 2.0, 3.01, 3.03, 3.04, 3.05, 4.0, and 9.07.) 符合规定个定个案 ( 客户客 ): 个案主可能是任何适用行为分析服实的人, 但是, 受督导人不得与案 主有亲戚关系, 不得与案主的主要照顾者有亲戚关系, 不得为案主之主要照顾者 在实践经经累计期间, 受督导人必须和多位案主工作 ( 可参见下列相关的 BACB 行为分析师之责任行为准则, 条文 1.06, 1.07, 2.0, 3.01, 3.03, 3.04, 3.05, 4.0, 与 9.07) SUPERVISOR QUALIFICATIONS: During the experience period, the supervisor must be a Board Certified Behavior Analyst or Board Certified Behavior Analyst-Doctoral in good standing. The supervisor may not be related to, subordinate to, or employed by the supervisee during the experience period. Employment does not include compensation received by the supervisor from the supervisee for supervision services. (Also, see the following relevant sections of the BACB Guidelines for Responsible Conduct for Behavior Analysts: 1.05, 1.06, 1.07, and 5.0.) 督导者的者的资格规定 : 在经经累计期间, 督导人必须是声誉良好的师师行为分析师 BCBA 或师师行为分析师 - 博士 BCBA-D. 于经经累计期间, 督导不得为个案亲戚, 不得为其属下, 不得被其雇用 雇用关系不包括受督导人付给督导人, 用以偿付督导服实的费用 ( 可参见下列相关的 BACB 行为分析师之责任行为准则, 条文 1.05, 1.06, 1.07, 与 5.0) NATURE OF SUPERVISION: The purpose of supervision is to improve and maintain the behavioranalytic, professional, and ethical repertoires of the supervisee and facilitate the delivery of highquality services to his/her clients. Effective behavior-analytic supervision includes: 督导的本质 : 督导目的为增进并维维受督导人之行为分析的, 专专的, 与合乎伦理的整体表现, 以及促进受督导人提供优优服实给他或她的个案 有效能的行为分析督导包括 : Development of performance expectations 制定预期员效 Observation, behavioral skills training, and delivery of performance feedback 观察, 行为技能训训, 提供员效反馈 Modeling technical, professional, and ethical behavior 对受督导人示范技术上, 专专化, 和合乎伦理的行为 Guiding behavioral case conceptualization, problem-solving, and decision-making repertoires Page 6 of 14

7 指导受督导人的行为上概念, 解决问问, 和作决策的能力 Review of written materials (e.g., behavior programs, data sheets, reports) 审核书写材料 ( 例如行为计划, 数据表, 报告等 ) Oversight and evaluation of the effects of behavioral service delivery 监督与评量行为服实的效果 Ongoing evaluation of the effects of supervision 对督导效果的持续评量 The supervisor must observe and provide feedback to the supervisee on his/her behavior-analytic activities with a client in the natural environment during each required supervisory period. In-person, on-site observation is preferred. However, this may be conducted via web-cameras, videotape, videoconferencing, or similar means in lieu of the supervisor being physically present; synchronous (real-time) observation is strongly encouraged. 督导必须就每一督导期间, 受督导人在自然环境中与案主之间的行为分析活动, 予以观察并提供反馈给受督导人 最好是督导者本人实地的观察 但是可以通过网路摄像, 记像, 视视会议或类似方法, 代替督导者实地观察 我们们烈建议同步 ( 实导 ) 观察 Supervision may be conducted in small groups for no more than half of the total supervised hours in each supervisory period. Small groups are interactive meetings in which 2-10 supervisees who share similar experiences participate in the supervision activities described above. If non-supervisees are present during the meeting, their participation should be limited so as to increase the interaction opportunities of supervisees. The remainder of the total supervision hours in each supervisory period must consist of individual supervision. 督导可用小团体方式进行, 导数不超过每个督导期间总导数的一半 小团体督导为互动会议方式,2-10 名拥有相近实践经经的受督导人, 共同参与上述之督导活动 如有非受督导人参加会议, 他们的参与应应限于提高受督导人之间的互动机会 每一段督导期间, 除此之外余下的督导导数都必须由个类督导方式构成 SUPERVISION CONTRACT: The supervisee and supervisor must execute a written contract prior to the onset of the experience. The purpose of the contract is to protect all involved parties and align experience activities with the purpose of supervision described under Nature of Supervision (below). The contract should: 督导合约 : 在经经累计开始前, 受督导人和督导人必须执行书面合约 合约之目的为保维所有参与各方, 以及保持经经累计活动与督导性优所述目的 ( 见以下 ) 一致 合约应有 : State the responsibilities of the supervisor and supervisee; and 载明督导人和受督导人的责任 ; 及 Include a description of the appropriate activities and instructional objectives; and 包括对适当活动的描述, 以及教学目标 ; 及 Include the objective and measurable circumstances under which the supervisor will sign the supervisee s Experience Verification Form when the experience has ended; and 包括在客观与可测量的情况下, 当实践经验累计期结束时, 督导人会在实践经验证明核实表上签字 ; 及 Delineate the consequences should the parties not adhere to their responsibilities (including proper termination of the relationship); and Page 7 of 14

8 描述当一方或双方不遵守他们的责任 ( 包括适当地终止关系 ) 导, 会发生的后果 ; 及 Include a statement requiring the supervisee to obtain written permission from the supervisee s on-site employer or manager when applicable; and 包括一份声明, 要求受督导人在必要导须取得现现雇主或经理的书面许可 ; 及 Include an attestation that both parties will adhere to the BACB Guidelines for Responsible Conduct for Behavior Analysts and the BACB Disciplinary and Ethical Standards 包括一份签计, 表明双方将遵守 BACB 行为分析师责任行为准则, 与 BACB 纪律与伦理标准 The supervisee and supervisor are responsible for retaining and providing to the BACB, if requested, a copy of the contractual agreement. 受督导人与督导人有责任保存此督导合约, 在 BACB 要求导可以提供 BACB 此一份合约 DOCUMENTATION OF ONGOING SUPERVISION: The supervisee and supervisor are responsible for collecting documentation for each supervision period on the Experience Supervision Form during each supervisory period. One form should be completed at the end of each supervisory period. The BACB reserves the right to request this documentation at any time following an individual s application to take the certification exam. This documentation should NOT be submitted with an exam application unless specifically requested by the BACB. 进行中的督行中的督导导导 : 受督导人和督导人对每一督导期内的实践经经督导表单都负有收集文件 记记之责, 每一督导期计束导均应完成一份记记表 BACB 保留权利, 可以在申请人申请师师考试之后的任何导候要求该记记 申请考试导不需呈交该记记, 除非 BACB 特类要求 Supervisors may develop their own version of the Experience Supervision Form. These alternative forms must include all of the following elements: 督导人可以制作自己版本的实践经经督导表单 这些替代表单必须包括所有下述元素 : Date of each supervisory meeting 每一次督导会议的日期 Duration of each supervisory meeting 每次督导会议的导间时度 Format of each supervisory meeting (i.e., individual or small group) 每次督导会议的形式 ( 即个类或小团体 ) An evaluation of supervisee performance 对受督导人员效 ( 表现 ) 的评量 The total experience hours obtained during the supervisory period 每次督导期间取得之实践经经总导数 The total individual and small-group supervision hours obtained during the supervisory period 每次督导期间取得之个类与小团体督导总导数 Date lines for supervisor and supervisee indicating when the form was completed & signed 督导人与受督导人签字之日期栏, 显示表单何导完成 Signature lines for supervisor and supervisee 督导人与受督导人签字栏 Page 8 of 14

9 The supervisee and supervisor are responsible for retaining and providing to the BACB, if requested, copies of supervision documentation. Supervision documentation should be retained for at least 7 years. 受督导人与督导人自行负责保有督导记记文件, 并在 BACB 要求导提供文件, 督导记记文件应保留七年 The BACB Experience Standards and Forms were updated in September Please be sure to use the current version, available in the Downloads section of All applicants for certification must submit documentation of their experience using the current version of the Experience Verification Form. Previous versions of the form will no longer be accepted. BACB 实践经经规定与表单曾于 2012 年九月更新, 请确保使用目前最新版本, 表格可在 的下载 (Downloads) 栏目中得到 所有申请师师者必须呈交目前最新版本的实践经经师明表单, 先前的版本不再被接受 CONTESTED EXPERIENCE: If a supervisee is unable to obtain the signature of a supervisor on the Experience Verification Form or disagrees with the total number of hours recorded on the form, the supervisee may supplement his or her application with proof of the following: 具争執性的性的实践经经 : 如果受督导人不能取得督导人在实践经经核实表单上签字, 或不同意表单所记记之总导数, 受督导人可以在申请导请充下列师据 : a. A copy of the supervisory contract 一份督导合约 b. Copies of the signed Experience Supervision Forms completed during the experience 一份具名签字的, 于经经累计期间完成的实践经经督导表单 c. Letters or other documentation from third parties who observed the supervisory relationship 由观察督导关系的第三方发出的信或其他文件 Supervisees also must provide the supervisor with copies of the documentation they are submitting to the BACB and must include proof of provision of this information to the supervisor (e.g., certified mail receipt along with a letter from the supervisee to the supervisor). The BACB may attempt to contact the supervisor to confirm receipt of this information and to provide him or her with an opportunity to address this matter in writing. Supervisors will be asked to provide documentation of dissatisfaction/concerns regarding the experience previously provided to supervisees claiming a contested supervision. If the application is denied based on the lack of proof of supervision, supervisees will have a right to appeal this denial. 受督导人也需要将呈交给 BACB 的文件記錄提供副本给督导人, 同导必须包括已提供该信息给督导人的师明,( 例如挂号信收据, 连同受督导人写给督导人的信 )BACB 得尝试尝系督导人以确师收到该信息, 并提供督导人以书面方式解释问问的机会 督导人将被要求提供记记, 以显示对宣称对督导持异议的受督导人之不满意 / 有所担忧之处 Page 9 of 14

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11 (BACB Experience Supervision Form) BACB 实践 实践经经督导表 This form (or equivalent) must be completed at least once during each supervisory period. 本表单 ( 或等同表单或 ) 必须在每次督次督导期间至少完成一次 Supervisee 受督导人 : Supervisor 督导人 : Supervisory Meeting Date(s) & Duration(s) 督导会面日期与会面日期与时时时度 : Supervisory Meeting Format (check all that apply) 督导方式 ( 可複选 ): individual 个别 group 团体 This document covers the supervisory period from 本文件函盖督盖督导期时自 / / to 至 / / Experience Hours Accumulated During This Supervisory Period 于本督导期时内的内的实践经经时数累数累计 (complete all four lines) ( 四行全部填写 ) A) Number of independent experience hours accumulated (excluding time spent with supervisor) 独立实践时数累计 ( 与督导人互动时动不算 ): Of the hours listed above, state the number spent in direct implementation of behavioral programs: 上述时数中, 多少小时是用在行为为程的直接执行 : B) Number of individual supervision hours accumulated 个别督导时数累计 : C) Number of small-group supervision hours accumulated 小团体督导时数累计 : D) Total experience hours accumulated (add lines A through C) 总总总时数累计 (A 至 C 栏相加 ): Characteristics of Supervision Conducted During This Supervisory Period (check all that apply) 于本督导时时内的督内的督导要点 ( 适用者均可勾用者均可勾选 ) BACB Task List skills covered (list Task numbers) 已涵盖之 BACB 工作任务表技能 ( 列出工作号码 ): Specific client(s) discussed 已讨讨特定个案 Client privacy protected 已保护个案之隐私 Observation of supervisee (video) 对受督导人之观察 ( 视视录像 ) Observation of supervisee (in-person) 对受督导人之观察 ( 现现 ) Supervisory discussion & feedback (in-person) 督导下的讨讨及反馈 ( 现现 ) Supervisory discussion & feedback (remote) 督导下的讨讨及反馈 ( 远距离 ) Readings 阅阅 : Evaluation of Supervisee Performance 对受督受督导人表人表现之评量 : S - Satisfactory 满意 NI - Needs Improvement 需要改进 U- Unsatisfactory 不满意 N/A - Not Applicable 不适用 Arrives on time for supervision 准时到达督导导合 Maintains professional and courteous interactions with 秉持专专化及有礼的互 有礼的互动 : 和个案 / 消费者和其他的服务提供者和同事保持适当穿着和言行当穿着和言行举止自我专专的提昇可以合宜地接地接纳督导人的反人的反馈会适当地当地寻求督导呈交书面报告有效地沟通 : 面上 Clients/consumers Other service providers 和其他的服 Coworkers Maintains appropriate attire & demeanor 保持 Initiates professional self-improvement 会主动从事自我 Accepts supervisory feedback appropriately 可以合宜 Seeks supervision appropriately Timely submission of written reports 准时呈交 Communicates effectively: 有效 Written 书面上 Oral 口语上 Demonstrates appropriate sensitivity to nonbehavioral providers 对非行非行为服务者展者展现适当的敏感度 可以自我檢查个人之个人之局限自我檢查专专能力之能力之局限分析技能 Supervisee self-detects personal limitations 受督导人可以自我檢个人之 Supervisee self-detects professional limitations 受督导人可以可以自我 Acquisition of target behavior-analytic skills 具备对于目标行为的分析技能 S NI U NA Overall evaluation of supervisee performance during this period (circle one): S NI U 受督导人在本期人在本期间内表内表现之总体评量 ( 圈选一项 ) Page 11 of 14

12 受督 BACB Experience Standards ver. 1/13/14 (BACB 实践规规 1/13/14 版本 ) Supervisee signature 受督导人签名 : Supervisor signature 督导人签名 : Date 日期 : 日期 Date 日期 : 日期 勿呈交本表本表单 DO NOT SUBMIT THIS FORM TO THE BACB WITH THE EXAM APPLICATION 申请考试时勿呈交 SUPERVISOR AND SUPERVISEE MUST EACH RETAIN A COPY OF THIS FORM FOR AT LEAST 7 YEARS 督导人与受督人与受督导人必人必须各自各自保留保留本表本表单至少七年 Page 12 of 14

13 BACB Experience Verification Form (BACB 实践经经证明单 ) SECTION 部分 A 部分 Use one form per experience. Applicants may accrue only one type of experience at a time. 每一项实践经经使用一使用一份表单. 申请人一次只能累人一次只能累计一种方式的方式的实践经经. Applicant s Name 申请人姓名 :, (Last Name 姓 ) (First Name 名 ) 数累计 ( 三行全部填写 ): ) A) Number of independent experience hours accumulated 独立经经经数累计 : Of the hours listed above, state the number spent in direct implementation of behavioral programs: 上述经数中, 多少小经是用在行为为程的直接执行 : B) Number of supervision hours accumulated 督导经数累计 : Experience Hours Accumulated (complete all three lines) 实践经经经数累 C) Total experience hours accumulated (add lines A and B) 总经经经数累计 (A 与 B 栏相加 ): Experience Type Obtained (check only one) 所获实践经经经经 ( 只勾选一项 ): Supervised Independent Fieldwork 在督导下的独立实地工作 BACB Approved University Practicum (transcript must show passing grade in approved courses) BACB 核准之大学实实为 BACB Approved University Intensive Practicum (transcript must show passing grade in approved courses) BACB 核准之大学密集实实为 Experience Time-Frame 经经取得之取得之时间范围 : Starting date 起始日期 (M/D/Y) / / Ending date 结束日期 ( 月 / 日 / 年 ) / / (Indicate specific date 写出明确日期, 勿写 目前 ) Supervisor s Name 督导人姓名 人姓名 : Supervisor s Title 职职 : Telephone 督导人电电号码 : Experience Setting 实实场所 : 城市 : State/Country 省 / 国家 : City 城市 SECTION 部分 B Must be completed by supervisor 必须由督 由督导人填写完成 By signing below, I hereby attest that 经由以下由以下签名, 本人谨此证证 : The applicant completed the experience as specified in this policy document under my supervision and in compliance with all of the stated requirements. 申请人在人在本人本人督导下, 完成本政策规定的, 并达成所有列所有列举的要 求 人在本人 下, 完成本政策 定的实实经经, 并 所有列 I am the responsible supervisor designated in the supervision contract with this supervisee. 本人 合约中的责任督任督导, 督导合约为此受督此受督导人与人与本人本人所订立 During the applicant s experience I was a Board Certified Behavior Analyst 在申请人累人累计经经期间, 本人为合格合格认认行为分析分析师,BCBA 认照号照号码 # 的要 本人为督导 Supervisor: By signing below, you attest that ALL of the information contained on this Experience Verification Form is true and correct to the best of your knowledge. 督导人 : 经由以下由以下签名, 你证证证份表单包含之包含之所有所有信息均信息均为尽你所知的所知的真证而且正而且正确 人姓名 : Printed Name of Supervisor 督导人姓名 Signature 签名 : 日期 : Date 日期 Page 13 of 14

14 This document must bear the original signature of the supervisor. Photocopies, faxed, or ed copies of this document will not be accepted. Original documents that have been altered (white-out, strike-through, etc.) will not be accepted. Incomplete documents will not be accepted. 本文件必须须有督导人的原始签名 复印, 传真, 或电电副本均不被接受 被改造之原始文件 ( 用修正液, 画掉, 等等 ) 不被接受 不完整的文件不被接受 Page 14 of 14