8. Total number of practicum hours: _________________Number of hours assumed full responsibility in the role: ______________________ 9. Other Massachusetts licenses held if any:... more
8. Total number of practicum hours: _________________Number of hours assumed full responsibility in the role: ______________________ 9. Other Massachusetts licenses held if any: _________________________________________________________________________________ 10. Have any components of the approved program been waived (see Regulations 7.03(1)(b)): Yes _______________No___________________ Date: ________Applicant: _______________ Program Clinical Supervisor: _____________ Supervising Practitioner: __________________ 3. Final meeting held to complete evaluation and to allow Applicant an opportunity to raise questions and make comments. Date: ________Applicant: _______________ Program Clinical Supervisor: _____________ Supervising Practitioner: __________________ Part V Candidate has successfully completed the Pre-service Performance Assessment (Sections: 7.03(2)(a)(4) & 7.04(2)(b)(4)(b)) Yes: _____No: _____ Program Clinical Supervisor (sign): _____________________________________________________________ Date: _____________________ Supervising Practitioner (sign): _________________________________________________________________ Date: _____________________ Mediator (if necessary: see 7.04(4))(sign): _________________________________________________________ Date: _____________________
