HEALTH LICENSING OFFICE Behavior Analysis Regulatory Board

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1 HEALTH LICENSING OFFICE Behavior Analysis Regulatory Board 700 Summer St. NE, Suite 320, Salem, OR, Phone: Fax: BEHAVIOR ANALYSIS INTERVENTIONIST REGISTRATION APPLICATION 1. Applicant Information APPLICANT NAME: LAST FIRST MIDDLE INTIAL RESIDENTIAL PHYSICAL ADDRESS (REQUIRED) CITY STATE ZIP MAILING ADDRESS (IF DIFFERENT FROM RESIDENTIAL ADDRESS) CITY STATE ZIP PHONE: HOME CELL BUSINESS TELEPHONE GENDER BIRTHDATE SOCIAL SECURITY NUMBER or TAX IDENTIFICATION NUMBER (REQUIRED) Female Male Have you ever been known under any other name? No Yes If yes, list full name(s): Do you hold or have you previously held licensure, certification or registration with the Health Licensing Office or any other state? No Yes - If yes, please list information below. State: Lic./Cert./Reg.# Expiration: State: Lic./Cert./Reg.# Expiration: State: Lic./Cert./Reg.# Expiration: State: Lic./Cert./Reg.# Expiration: 2. Supervisor Information (IF AVAILABLE AT TIME OF APPLICATION) SUPERVISOR NAME: SUPERVISOR S BARB LICENSE/REGISTRATION#: 3. ***(Complete This Section Only If Submitting Payment By Mail)*** Method Of Payment For Application Fee = $75; Registration Fee = $100 Please check one: Cash Check Money order Purchase order Credit card (see below) Type of Credit Card: Visa MasterCard Discover (Cardholder must either be the applicant or be present at the time application is submitted) Do Not Fax or Credit Card Information Name on card: Card number: Exp: Authorized amount: $ Cardholder signature: Do not write in this section Official use only Initials OTC ID Verified BACB Cert. Verified LEDS Completed HSD/GED Received Pathway 1 Documents Received Pathway 2 Documents Received Application continued on the next page

2 4. Individual Records Questions: Please accurately answer all of the questions below. The Office may review your information through the Law Enforcement Data System, other governmental agencies, and private vendors to confirm the accuracy of the information. Any misrepresentation or failure to disclose information may result in disciplinary action. Are you now, or have you ever been, the subject of any active or inactive disciplinary action or voluntary resignation of a professional license, certificate, registration or permit imposed by a licensing or regulatory authority in this or any other state? Disciplinary action includes, but is not limited to, probation, suspension, civil penalty, or any other sanction limiting, in any way, a license, certificate, registration or permit. Yes No If yes, please explain: Have you ever been convicted of a misdemeanor or felony? Yes No If yes, please list all convictions, including the charges as stated in the court documents and year convicted (attach additional pages if necessary). Year Convicted As of today are you on probation or parole? Yes No If yes, you must provide a letter of release from your probation or parole officer authorizing you to obtain an authorization to practice. If you are on bench probation, or probation with the court, you must provide documentation of your conditions of the probation. As part of your application for initial or renewed occupational or professional license, certification, or registration issued by the Health Licensing Office, you are required to provide your Social Security number (SSN) to the Office. This is mandatory. The authority for this requirement is ORS , ORS , 42 USC 405(c)(2)(C)(i), 42 USC 666(a)(13), and 41 CFR Failure to provide your SSN will be a basis to refuse to issue or renew the license, certification, or registration you seek. This record of your SSN is used for child support enforcement, tax administration purposes (including identification), and if any disciplinary action is taken against your license, certification, or registration, your SSN may be reported to the federal Health Care Integrity and Protection Data Bank. The HLO will use your SSN for these purposes only, unless you authorize other uses of the number. Your SSN will remain on file with the Office. I have examined this application and certify that it is true, correct, and complete. I understand that knowingly making a false statement on this application will be cause for denial, suspension, or revocation of my license, certification or registration. I have enclosed the required fees and documentation. Applicant Signature: ORS , , and authorize the Health Licensing Office to conduct criminal background checks and the office requests that you voluntarily provide your Social Security number for this purpose. I understand my application may be subject to a criminal background check. Failure to provide your Social Security number for this purpose will not be used as a basis to deny your application, or to deny you any right, benefit or privilege provided by law. If you consent to the use of your Social Security number by the HLO for this purpose, it may be used only for criminal records checks. I hereby voluntarily consent to disclose my Social Security number to the HLO for criminal background checks. Applicant Signature: HOURS OF SKILLS TRAINING INFORMATION (see BARB knowledge and skills training form) Training was obtained prior to January 1, 2015, and trainer held a current certification as a Behavior Analyst or Assistant Behavior Analyst with the Behavior Analyst Certification Board (BACB), or was a health care professional licensed pursuant to ORS : Training was obtained after January 1, 2015, and trainer held a current license as a Behavior Analyst or Assistant Behavior Analyst with the Behavior Analysis Regulatory Board (BARB), or was a licensed Health Care Professional (HCP) registered with BARB pursuant to ORS : TRAINER S NAME: LAST FIRST MIDDLE INTIAL TRAINER S BACB CERTIFICATION#/HCP LICENSE#/BARB LICENSE-REGISTRATION#: Applicant Signature:

3 6. Affirmative Action Voluntary Question The State of Oregon has an Affirmative Action Policy. If you choose to provide this information, it will help us evaluate the effectiveness of our affirmative action programs. This information will also be used in the aggregate (i.e. as a whole, not individually) for research and statistical purposes. It will not be tied specifically or directly to your licensing information. Ethnic Background (check only one) (A) Asian or Pacific Islander: Persons having origins in any of the peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands and Samoa. (B) African American (not of Hispanic origin): Persons having origins in any of the Black racial groups of Africa. (H) Hispanic: Persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish cultures or origin, regardless of race. (I) American Indian or Alaskan Native: Persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. (W) Caucasian (not of Hispanic origin): Persons having origins in any of the original peoples of Europe, North Africa or the Middle East. REQUIREMENTS FOR BEHAVIOR ANALYSIS INTERVENTIONIST REGISTRATION Submit a completed application form prescribed by the Board, which must contain the information listed in OAR and be accompanied by payment of the required application fees = $75 (see method of payment section above); Submit one form of identification: Front and back of acceptable photographic identification listed in OAR ; driver license, state ID card, passport or military ID card. Legible (clear) photocopies if submitted by mail; Submit documentation of a high school diploma or equivalent; Successfully complete a LEDS criminal records check conducted by the Health Licensing Office; Provide documentation for one of the qualification pathways (see pathways on following page); Submit required registration fee = $100 (see method of payment section above); and Submit documentation of 40 hours of training in the knowledge and skills itemized in the BARB Interventionist Knowledge and Skill Training form. If the training was obtained before January 1, 2015, the training must have been provided by: a (BACB) Board Certified Behavior Analyst, a (BACB) Board Certified Assistant Behavior Analyst or a health care professional licensed pursuant to ORS ; If the training was obtained after January 1, 2015, the training must have been provided by a (BARB) licensed (BACB) Board Certified Behavior Analyst, a (BARB) licensed (BACB) Board Certified Assistant Behavior Analyst or a licensed health care professional (BARB) registered pursuant to ORS NOTE: See section 5 on the registration application. Qualification Requirements Continued On Next Page

4 PATHWAY ONE: QUALIFICATION THROUGH COURSEWORK AND TRAINING Applicant must: Submit proof of at least 30 quarter credit hours or equivalent semester credit hours from an accredited university or college with at least 3 credit hours in one of the following areas of study: Special Education; Human development; Early childhood development; Introduction to psychology; Behavior psychology; Education; or Speech/language pathology; and PATHWAY TWO: QUALIFICATION THROUGH COURSEWORK AND ON-THE-JOB TRAINING Applicant must: Submit proof of at least 3 quarter credit hours or equivalent semester credit hours from an accredited university or college in one of the following areas of study: Special Education; Human development; Early childhood development; Introduction to psychology; Behavior psychology; Education; or Speech/language pathology. Submit proof of having at least 1,000 hours of supervised experience acquired in the last three years delivering applied behavior analysis treatment protocols. If the supervised experience listed above was obtained prior to January 1, 2015, it must have been provided by: a (BACB) Board Certified Behavior Analyst, a (BACB) Board Certified Assistant Behavior Analyst or a health care professional licensed pursuant to ORS ; If the supervised experience listed above was obtained after January 1, 2015, it must have been provided by a (BARB) licensed (BACB) Board Certified Behavior Analyst, a (BARB) licensed (BACB) Board Certified Assistant Behavior Analyst or a licensed health care professional (BARB) registered pursuant to ORS NOTE: See supervised work experience verification form.

5 HEALTH LICENSING OFFICE Behavior Analysis Regulatory Board 700 Summer St. NE, Suite 320, Salem, OR, Phone: Fax: INTERVENTIONIST KNOWLEDGE AND SKILLS TRAINING Please refer to the attached BARB Interventionist ABA Knowledge and Skills list. Using the knowledge and skills list, record the formal training received in each of the categories below including the date, location, training provider and hours for each of the categories. Attach additional pages as needed. TRAINING ACTIVITY DATE LOCATION Knowledge and Skills Categories (40 hours) PROFESSIONAL AND ETHICAL ISSUES TRAINING PROVIDER AS DEFINED BY RULE HOURS FOUNDATIONAL KNOWLEDGE OF BEHAVIORAL CHANGE PRINCIPLES ASSESSMENT IMPLEMENTATION OF PRESCRIBED INTERVENTION PLANS DATA COLLECTION AND DOCUMENTATION The cumulative duration of the training must total at least 40 hours for the knowledge and skills categories listed above. Total hours = By signing below, I attest that the above training was completed. Applicant Signature: Trainer Signature:

6 INTERVENTIONIST ABA KNOWLEDGE AND SKILLS LIST I. Professional and Ethical Issues Task Description Abide by employer, state & federal regulations regarding procedures for storing, transporting and sharing I-1 confidential electronic or paper documents or files with client identifying information I-2 Abide by employer, state & federal reporting regulations (e.g., mandatory reporting laws) I-3 Describe the role of the registered interventionist based on BARB requirements I-4 Communicate with colleagues, caregivers, other stakeholders as indicated by supervisor I-5 Demonstrate professional behavior in family homes, schools, community environments I-6 Recognize and prevent perceived or actual conflicts of interest or dual relationships I-7 Recognize situations requiring additional supervision and request in appropriate timeframe I-8 Identify characteristics of populations served (e.g., autism, intellectual disability, etc.) I-9 Understand and protect rights of consumers (e.g., using evidence-based practices, right to effective treatment, applicable state/federal laws) I-10 Accept (and apply) performance feedback on maintenance or improvement of skills II. Foundational Knowledge of Behavioral Change Principles II-1 II-2 II-3 II-4 III. Assessment III-1 III-2 III-3 Define Applied Behavior Analysis (ABA) and its relation to experimental, theoretical, and radical behaviorism Define behavior & provide operational definitions Demonstrate stimulus control transfer procedures Discuss functions of behavior (e.g., socially mediated, automatic) Contribute to standardized or curriculum-based language, play, academic, or adaptive behavior assessment as trained and indicated by supervisor Contribute to functional behavior assessment (indirect vs. direct methods; collect ABC data, functional analysis etc.) Implement systematic preference assessments to identify potential reinforcers IV. Implementation of Prescribed Intervention Plans IV-1 IV-2 IV-3 IV-4 IV-5 IV-6 IV-7 IV-8 IV-9 IV-10 IV-11 IV-12 IV-13 IV-14 IV-15 HEALTH LICENSING OFFICE Behavior Analysis Regulatory Board 700 Summer St. NE, Suite 320, Salem, OR, Phone: Fax: Continuous & intermittent schedules of reinforcement Antecedent-based interventions (motivating operations, choice etc.) Differential reinforcement procedures Extinction procedures Positive and negative punishment procedures Procedures that address generalization and maintenance Prompts and use prompting hierarchies Prompt fading Error correction procedures Discrete trial teaching procedures Task analyses (chaining) Shaping procedures Naturalistic teaching strategies (e.g., incidental teaching) Assisting with caregiver/stakeholder training as authorized by supervisor Prescribed crisis or emergency management procedures V. Data Collection and Documentation V-1 Prepare for session (data collection, materials) V-2 Collect data using continuous recording methods (frequency, duration, latency, IRT) V-3 Collect data using discontinuous recording methods (e.g., interval recording procedures) V-4 Collect data using permanent products methods V-5 Graph collected data V-6 Write objective and specific session notes (e.g., mastery of skills, difficulties, illness, etc.) V-7 Communicate with supervisor

7 HEALTH LICENSING OFFICE Behavior Analysis Regulatory Board Summer St. NE, Suite 320, Salem, OR, Phone: Fax: Behavior Analysis Interventionist Supervised Work Experience Verification (Pathway Two Only) Pursuant to OAR , the information on this form must provide documentation of 1,000 Hours of supervised experience acquired in the last three years delivering applied behavior analysis treatment protocols. Complete all parts of this form Attach additional pages as needed. Employer/Supervisor #1 EMPLOYER: EMPLOYER ADDRESS: CITY: STATE: DATES OF EMPLOYMENT: FROM: TO: Average Number Of Hours Per Week Applicant Provided Client Treatment Protocols: Supervisor Verification of Work Experience NAME OF SUPERVISOR: Supervisor s Health Care Professional License# / BACB certification #, or BARB license/registration #: (note: If training was after Jan. 1, 2015, you must list BARB license/registration #) Supervisor Signature: Applicant Signature: SUPERVISOR PHONE NUMBER: DATE OF REVIEW: Employer/Supervisor #2 (if applicable) EMPLOYER: EMPLOYER ADDRESS: CITY: STATE: DATES OF EMPLOYMENT: FROM: TO: Average Number Of Hours Per Week Applicant Provided Client Treatment Protocols: Supervisor Verification of Work Experience NAME OF SUPERVISOR: Supervisor s Health Care Professional License# / BACB certification #, or BARB license/registration #: (note: If training was after Jan. 1, 2015, you must list BARB license/registration #) Supervisor Signature: Applicant Signature: SUPERVISOR PHONE NUMBER: DATE OF REVIEW:

8 Behavior Analysis Interventionist Supervised Work Experience Verification (Pathway Two Only) (Continued) Pursuant to OAR , the information on this form must provide documentation of 1,000 Hours of supervised experience acquired in the last three years delivering applied behavior analysis treatment protocols. Complete all parts of this form Attach additional pages as needed. Employer/Supervisor #3 (if applicable) EMPLOYER: EMPLOYER ADDRESS: CITY: STATE: DATES OF EMPLOYMENT: FROM: TO: Average Number Of Hours Per Week Applicant Provided Client Treatment Protocols: Supervisor Verification of Work Experience NAME OF SUPERVISOR: Supervisor s Health Care Professional License# / BACB certification #, or BARB license/registration #: (note: If training was after Jan. 1, 2015, you must list BARB license/registration #) Supervisor Signature: Applicant Signature: SUPERVISOR PHONE NUMBER: DATE OF REVIEW: Employer/Supervisor #4 (if applicable) EMPLOYER: EMPLOYER ADDRESS: CITY: STATE: DATES OF EMPLOYMENT: FROM: TO: Average Number Of Hours Per Week Applicant Provided Client Treatment Protocols: Supervisor Verification of Work Experience NAME OF SUPERVISOR: Supervisor s Health Care Professional License# / BACB certification #, or BARB license/registration #: (note: If training was after Jan. 1, 2015, you must list BARB license/registration #) Supervisor Signature: Applicant Signature: SUPERVISOR PHONE NUMBER: DATE OF REVIEW:

9 Behavior Analysis Interventionist Supervision Agreement (Page 1 of 2) This form identifies the responsibilities of the Behavior Analysis Interventionist and the supervising Behavior Analyst, Assistant Behavior Analyst, or Licensed Health Care Professional. Both the applicant and supervisor must sign this document. A copy this agreement must be provided to the parent or guardian of each of the interventionist s clients and must be maintained in the supervisor s records for a period of at least five years as outlined in OAR Interventionist Information INTERVENTIONIST S NAME: LAST FIRST MIDDLE INTIAL DATE 2. Supervisor Information HEALTH LICENSING OFFICE Behavior Analysis Regulatory Board 700 Summer St. NE, Suite 320, Salem, OR, Phone: Fax: INTERVENTIONIST S NAME: LAST FIRST MIDDLE INTIAL DATE SUPERVISOR S PROFESSIONAL LICENSE: BEHAVIOR ANALYST ASSISTANT BEHAVIOR ANALYST BARB LICENSE/REGISTRATION # HEALTH CARE PROFESSIONAL - TITLE: EMPLOYER EMPLOYER PHYSICAL ADDRESS CITY STATE ZIP PROPOSED DATES OF SUPERVISION: FROM: TO: Brief description of the proposed supervised duties of the interventionist subject to this agreement (Use Additional Sheets Of Paper If Necessary): Have you had a pre-existing working relationship with this interventionist? Yes No; if yes, how long have you known this interventionist? year(s) month(s); if yes, please describe the pre-existing working relationship between you and the interventionist (use additional sheets of paper if necessary): WHERE WILL SUPERVISION TAKE PLACE? SUPERVISOR'S OFFICE INTERVENTIONIST S OFFICE OTHER: EXPLAIN NAME OF FACILITY WHERE SUPERVISION WILL TAKE PLACE: ADDRESS OF FACILITY (PHYSICAL LOCATION): CITY: STATE: A Copy Of This Form Must Be Provided To The Parent Or Guardian Of The Client

10 Behavior Analysis Interventionist Supervision Agreement (Page 2 of 2) 3. Responsibilities Interventionist agrees that: My title will be Registered Behavior Analysis Interventionist and that I am not permitted, under Oregon Law, to be called or represent myself as a Licensed Behavior Analyst, Licensed Assistant Behavior Analyst, or Registered Health Care Professional. I will follow the Standards of Practice, Professional Methods of Procedures as specified in OAR Chapter 824, Division 60 and understand that failure to comply with these standards may constitute unprofessional conduct which is subject to discipline under ORS and ORS It is my responsibility to adhere to the direction and instruction of my supervisor in all areas of training and in my independent service delivery duties as an interventionist. I will provide any and all information to my supervisor, and to the Board, to ensure that protocols set-forth in Oregon Administrative Rules regulating my duties, responsibilities and services as an interventionist and as a supervisee, including the protocols set-forth in this agreement for the provision of my supervision, and agree to obtain prior approval of any modifications to this agreement; and I will maintain client confidentiality at all times, including during supervision, and will inform the Behavior Analysis Regulatory Board and Health Licensing Office of any changes to my registration records on file with the board. By signing below, I certify that the information provided in this document is true and correct to the best of my knowledge. I agree to work under this supervision agreement as described above. Interventionist Signature: Supervising Behavior Analyst, Assistant Behavior Analyst, Health Care Professional agrees that: I will provide a copy of this agreement to the parent or guardian of each client receiving independent service delivery from the interventionist that is subject to this agreement. I will complete a competency assessment on the interventionist subject to this agreement. I will meet and assess the client prior to the interventionist initiating independent service delivery. I will maintain oversight, as defined in OAR (12), of the interventionist for a minimum of 2 hours prior to independent service delivery with the client, which can be met through training. I will evaluate or assess the interventionist s performance at least every 6 months after the initial competency assessment. I will maintain a log of ongoing oversight of the interventionist on a form prescribed by the Behavior Analysis Regulatory Board. I will maintain oversight, as defined in OAR (10), during the interventionist s delivery of service caseload at least once every three months. I will notify the Behavior Analysis Regulatory Board within three business days if the interventionist is no longer being supervised. I will maintain the interventionist s supervision records for a minimum of five years after the last day of supervision and make those records available for inspection; and I will inform the Behavior Analysis Regulatory Board of any changes in practices or policies which may adversely affect the successful completion of this supervision agreement or compliance with the Board s regulation. By signing below, I certify that the information provided in this document is true and correct to the best of my knowledge. I agree to work under this supervision agreement as described above. Supervisor Signature: A Copy Of This Form Must Be Provided To The Parent Or Guardian Of The Client

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