2009 IA Supervised Clinical Experience: Approval and Attestation-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part 1, where the supervisor must fill in their name, mailing address, phone number, and email address. Ensure all fields are completed accurately.
3. Next, the supervisor should provide their education and license information, including title, degree/major, university attended, and license/certification details.
4. In the section for recent clinical experience, input the employer's name and state along with the duration of employment. Specify the type of setting.
5. Continue by detailing the planned supervised experience dates and employment settings. Include agency names, addresses, phone numbers, and email addresses as required.
6. For professional duties under supervision, describe tasks clearly. If more space is needed, feel free to add additional pages.
7. Finally, both supervisor and applicant must sign and date their respective attestations at the end of each part before submitting the form to the Iowa Board of Behavioral Science.

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