MA in Psychology: Behavior Analysis (MABA) Practicum Forms

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1 MA in Psychology: Behavior Analysis (MABA) Practicum Forms Please note that the MABA program requires two semesters of practicum. Practicum classes are available in the Fall and Spring semesters. You must be enrolled in Psyc 5930 (Practicum in Behavior Analysis) and an approved practicum site to count your hours for the BACB exam at a higher rate than one for one. You must complete the Experience Standards training module on the BACB website prior to starting your supervised experience. The minimum hour per week commitment is 10 and the maximum is 30. You must receive on-site supervision each week (once per week for 7.5% of the weekly hours for regular practicum and twice per week for 10% of the weekly hours for intensive practicum). You must carry student liability insurance. You need to complete forms MA1, MA2, MA3, MA5, and MA6 (listed below) and submit them to your practicum instructor prior to starting client work. You will complete MA4 each week you see clients and your supervisor. a) Request for Approval to Enroll in Practicum MA1 b) Agency Agreement MA2 c) Supervision Contract signed by your BCBA supervisor MA3 d) Weekly Summary of Hours of Experience (complete on an ongoing basis) MA4 e) Release of Liability for the University MA5 f) Acknowledgement of Practicum Requirements MA6

2 PSYCHOLOGY GRADUATE PROGRAM BOARD CERTIFIED BEHAVIOR ANALYST (BCBA) TRAINEE PRACTICUM REGISTRATION APPLICATION MA1 READ ALL MATERIALS CAREFULLY BEFORE COMPLETING THIS APPLICATION 1. CSUS Student ID# 2. Name: Last name First name Middle name Other names used Completed the BACB Experience Standards training module (online) (yes/no) 3. QUALIFYING DEGREE PROGRAM: A. of Admission to CSUS MABA Program: B. Expected Graduation : C. Did you have any conditions on your admission to the MABA Program: yes/ no NOTE: If yes please provide documentation that all conditions have been fulfilled. List the Practicum prerequisite courses you have completed MANDATORY COURSES PRIOR TO PRACTICUM UNITS DATE COMPLETED GRADE 1. PSYC 5080 Legal and Ethical Issues 3 2. PSYC 5055 Foundations of Behavior Analysis 3 3. PSYC 5750 Advanced Applied Behavior Analysis OR 4 PSYC 5150 Clinical Behavior Analysis OR 3 PSYC 5090 Behavioral Assessment 3 List the names of the individuals you can use as references. Be sure you have formally requested use of these individuals names to include in your application material List the agencies to which you intend to apply for practicum experience. Liability Insurance Carrier and Policy # I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT. I UNDERSTAND I AM RESPONSIBLE FOR SECURING A PRACTICUM SITE THAT MEETS BACB REQUIREMENTS. Trainee s Signature Graduate Academic Director s Signature Practicum Instructor s Signature

3 PSYCHOLOGY GRADUATE PROGRAM BOARD CERTIFIED BEHAVIOR ANALYST (BCBA) TRAINEE AGENCY LETTER OF AGREEMENT MA2 It is hereby agreed that (Name of agency) will Accept as a Board Certified Behavior Analyst (BCBA) trainee (Name of trainee) for the period of (Beginning date) to (Ending date) It is further agreed that the agency and the trainee will have the following responsibilities: The Agency shall: 1. Have a written contract with the trainee that specifies their duties (e.g., working hours, expected case load, mandatory staff meetings, etc.). 2. Keep current and adhere to all BACB regulations. 3. Adhere to all legal mandated reporting laws. 4. Provide a BACB qualified supervisor for the trainee. 5. Adhere to the following BACB guidelines: 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. 6. Encourage the supervisor to have a written plan for handling emergencies. 7. Enable the supervisor to conduct direct observations of the trainee according to BACB guidelines. 8. Enable the supervisor to review trainee case records and case presentations, monitor and evaluate the assessment and treatment decisions of the trainee. 9. Encourage the supervisor to notify the CSUS Psychology practicum class instructor if they have any questions or concerns about the trainee. 10. Provide adequate client contact and supervision so that the BACB Trainee can complete a minimum of 150 hours of supervised experience for the practicum class.

4 The BCBA Trainee shall: 1. Adhere to the current BACB Guidelines for Responsible Conduct for Behavior Analysts. 2. Adhere to all legal mandated reporting laws. 3. Be enrolled in Psychology 5930: Practicum in Behavior Analysis 4. Adhere to all agency policies, procedures, regulations and requirements as so agreed upon. 5. Carry professional liability insurance. 6. Notify all clients of their BACB Trainee status. I hereby agree to the above stated conditions: Agency Director BCBA Supervisor for trainee BCBA Trainee Please return the signed original copy of this form to: California State University, Stanislaus Psychology Graduate Director One University Circle Turlock, CA ONE UNIVERSITY CIRCLE TURLOCK, CALIFORNIA PHONE (209) FAX (209)

5 PSYCHOLOGY GRADUATE PROGRAM BOARD CERTIFIED BEHAVIOR ANALYST (BCBA) TRAINEE SUPERVISION CONTRACT INSTRUCTIONS MA3 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 by the BACB. The contract should: State the responsibilities of the supervisor and supervisee; and Include a description of the appropriate activities and instructional objectives; and Include the objective and measurable circumstances under which the supervisor will sign the supervisee s Experience Verification Form when the experience has ended; and Delineate the consequences should the parties not adhere to their responsibilities (including proper termination of the relationship); and Include a statement requiring the supervisee to obtain written permission from the supervisee s on-site employer or manager when applicable; and 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 Include a statement that the BCBA supervisor has completed the required BACB supervisor s training. The supervisee and supervisor are responsible for retaining and providing to the BACB, if requested, a copy of the contractual agreement. I have read and understand the supervision contract requirements and have provided a copy of this contract to the practicum class instructor. Student name Student signature

6 BACB Experience Supervision Form This form (or equivalent) must be completed at least once during each supervisory period. MA4 Supervisee: Supervisory Meeting (s) & Duration(s): Supervisor: Supervisory Meeting Format (check all that apply): individual group This document covers the supervisory period from / / to / / Experience Hours Accumulated During This Supervisory Period (complete all four lines) A) Number of independent experience hours accumulated (excluding time spent with supervisor): Of the hours listed above, state the number spent in direct implementation of behavioral programs: B) Number of individual supervision hours accumulated: C) Number of small-group supervision hours accumulated: D) Total experience hours accumulated (add lines A through C): Characteristics of Supervision Conducted During This Supervisory Period (check all that apply) BACB Task List skills covered (list Task numbers): Specific client(s) discussed Client privacy protected Observation of supervisee (video) Observation of supervisee (in-person) Supervisory discussion & feedback (in-person) Supervisory discussion & feedback (remote) Readings: Evaluation of Supervisee Performance: S satisfactory NI - needs improvement U - unsatisfactory N/A not applicable S NI U N/A Arrives on time for supervision Maintains professional and courteous interactions with: Clients/consumers Other service providers Coworkers Maintains appropriate attire & demeanor Initiates professional self-improvement Accepts supervisory feedback appropriately Seeks supervision appropriately Timely submission of written reports Communicates effectively Written Oral Demonstrates appropriate sensitivity to nonbehavioral providers Supervisee self-detects personal limitations Supervisee self-detects professional limitations Acquisition of target behavior-analytic skills Overall evaluation of supervisee performance during this period (circle one): S NI U Supervisee signature: : Supervisor signature: : DO NOT SUBMIT THIS FORM TO THE BACB WITH THE EXAM APPLICATION SUPERVISOR AND SUPERVISEE MUST EACH RETAIN A COPY OF THIS FORM FOR AT LEAST 7 YEARS

7 CALIFORNIA STATE UNIVERSITY, STANISLAUS: RELEASE OF LIABILITY, PROMISE NOT TO SUE, ASSUMPTION OF RISK AND AGREEMENT TO PAY CLAIMS MA5 I am a Psychology Department graduate student registered in a practicum class from (semester dates) to My practicum experience will be gained at (Agency) In consideration for being allowed to participate in this activity, on behalf of myself and my next of kin, heirs, and representatives, I release from liability and promise not to sue the State of California, the Trustees of The California State University, California State University, California State University, Stanislaus, and their employees, officers, directors, volunteers and agents (collectively "University") from any and all claims, including claims of the University's negligence, resulting in any physical or psychological injury (including paralysis and death), illness, damages, or economic loss or emotional loss I may suffer because of my participation in this activity, including travel to, from and during the activity. I am voluntarily participating in this activity. I am aware of the risks associated with traveling to/ from, participation in this activity, which includes but are not limited to physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and/ or death. I understand that these injuries or outcomes may arise from my own or other's actions, inaction, or negligence; conditions related to travel, and dancing; or the condition of the agency location(s) or facilities. Nonetheless, I assume all related risks, both known or unknown to me, of my participation in this activity, including travel to, from and during the activity. I agree to hold the University harmless from any and all claims, including attorney's fees or damage to my personal property, which may occur as a result of my participation in this activity, including travel to, from and during the activity. If the University incurs any of these types of expenses, I agree to reimburse the University. If I need medical treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance. I am 18 years or older. I understand the legal consequences of signing this document, including (a) releasing the University from all liability, (b) promising not to sue the University, (c) and assuming all risks of participating in this activity, including travel to, from and during the activity. I understand that this document is written to be as broad and inclusive as legally permitted by the State of California. I agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms. I have read this document, and I am signing it freely. No other representations concerning the legal effect of this document have been made to me. Student s Name Student s Signature Revised 12/2014 BH 7

8 PSYCHOLOGY GRADUATE PROGRAM ACKNOWLEDGMENT OF BEHAVIOR ANALYSIS CERTIFICATION BOARD AND CSU STANISLAUS PSYCHOLOGY GRADUATE PROGRAM REQUIREMENTS MA6 Students who intend to pursue certification as a Behavior Analyst should know that certain conditions set by the BACB may impact their eligibility to sit for the BACB exam. These and other conditions specific to the Master of Arts in Psychology with a Concentration in Behavior Analysis and The Master of Science in Psychology degree with a Concentration in Behavior Analysis appear below. INSTRUCTIONS: Please complete and return this form to the Graduate Program Director as soon as possible. Name: Last, First Middle Initial Address: Number and Street Apt. No. City Zip Phone (Daytime): Student ID Concentration in Behavior Analysis: MA MS Semester started Program: By signing below, I acknowledge that I have read and understood the following: A. The Master of Arts in Psychology degree with a Concentration in Behavior Analysis or The Master of Science in Psychology degree with a Concentration in Behavior Analysis that I will obtain through California State University, Stanislaus (CSUS) is designed to meet the requirements of the Behavior Analysis Certification Board (BACB). B. The Master of Arts in Psychology degree with a Concentration in Behavior Analysis and The Master of Science in Psychology degree with a Concentration in Behavior Analysis are the only CSU Stanislaus degrees that are certified by the BACB. If I do not complete the specified program of study within one of these programs, I will not be eligible to be certified by the BACB as a graduate of a BCBA master s program. C. I am responsible for reading and understanding the relevant BACB regulations, the Psychology Department Graduate Handbook, and the CSUS catalog. D. I may not be able to qualify for practicum if I have been convicted of, or pled guilty or nolo contendre to, any misdemeanor or felony. I will not need to disclose offenses prior to my 18th birthday or any traffic violations for which a fine of $500 or less was imposed. If this section applies to me, I will contact the BACB at once to determine my eligibility for the BACB certification. E. I will need to disclose if I have ever been denied a professional license, or if my license privileges have ever been suspended, revoked, or if I have been otherwise disciplined, or if I have ever voluntarily surrendered any such license. F. My continuation in the program is based on maintaining both academic and behavioral standards. My suitability for the behavior analysis profession will be evaluated by BCBA faculty, practicum instructors, and clinical supervisors. G. Although the CSUS program is approved by the BACB, I realize I may need to complete additional supervised experience hours and must pass the national BACB exam to become a BCBA. Student s Signature: : ONE UNIVERSITY CIRCLE TURLOCK, CALIFORNIA PHONE (209) FAX (209) Revised 12/2014 BH 8

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