1. (a) The “Supervision Form” shall:

   1. (1) Include the information specified in (b) and (c), below and;

   2. (2) Be signed and dated by the supervisor below the following preprinted statement which asserts:

      “By signing this form I state that I have read and understood the applicable rules of supervision or order of the Board for supervision, agree to undertake the duties of supervision set forth in the rules or order of the Board, agree to be responsible for the acts and omissions of any person to whom I delegate the duties of supervision, and acknowledge that my own or my delegate’s failure to comply with the rules or order of the Board might result in disciplinary sanctions.”

2. (b) The first section of the “Supervision Form”, shall be completed by the person being supervised and shall include:

   1. (1) The name and license number of the person being supervised;
   2. (2) A description of the purpose of the supervision;
   3. (3) A check mark to indicate if the person being supervised is a provisional licensee; and
   4. (4) The name, mailing address, and telephone number of the place of employment of the person being supervised.

3. (c) The second section of the “Supervision Form”, shall be completed by the supervisor and shall include:

   1. (1) The name, profession, license number, and state of licensure of the supervisor;
   2. (2) The name, mailing address, and telephone number of the supervisor’s place of employment;
   3. (3) The name, location, and phone number of the site where the supervision will take place; and
   4. (4) The dates the supervision started and ended.

Source. #10686, eff 10-7-14; ss by #13555, eff 4-11-23; ss by #14337, eff 10-7-25, EXPIRES: 10-7-35