1. (a) The supervision form shall be the “Supervision Form” approved by the office of licensed allied health professionals board of directors on April 12, 2018.

2. (b) The individual to be supervised shall:

   1. (1) Legibly complete the portion of the “Supervision Form”, revised 4/12/18, designated “to be completed by the person to be supervised”; and
   2. (2) Complete in ink or using a keyboard;

3. (c) The individual who intends to provide supervision shall submit to the board a completed “Supervision Form”, revised 4/12/18, for which the supervisor shall:

   1. (1) Legibly complete the portion of the form designated “to be completed by the supervisor”;
   2. (2) Complete in ink or using a keyboard; and
   3. (3) Sign and date the form.

4. (d) The signature required on the form in (c) above shall attest to the fact that the supervisor:

   1. (1) Has read and understands the rules or order of the board governing the supervision;
   2. (2) Agrees to undertake the duties of supervision;
   3. (3) Agrees to take responsibility for the acts and omissions of any individual to whom the signer delegates the duties of supervision; and
   4. (4) Agrees with the statement of understanding that the failure of the signer or the signer's delegate to follow the rules or order of the board governing the supervision has the potential to subject the signer to disciplinary sanctions.

Source. #12725, eff 2-15-19; renumbered by #12846 (formerly Ahp 601.05)