1. (a) The supervision form shall:

   1. (1) Be completed using the “Supervision Form” dated March 25, 2015;
   2. (2) Be provided by the board and available on the boards web site, www.nh.gov/alliedhealth;
   3. (3) Be completed legibly in ink or using a keyboard; and

   4. (4) Be signed and dated 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 signature required by (b)(4) above shall constitute the signer's:

   1. (1) Assertion that the signer has read and understood the rules or order of the Board governing the supervision;
   2. (2) Agreement to undertake the duties of supervision;
   3. (3) Agreement to take responsibility for the acts and omissions of any individual to whom the signer delegates the duties of supervision; and
   4. (4) 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. (See Revision Note at chapter heading for Spe 300) #9125, eff 4-5-08; ss by #10906, eff 8-7-15