CLINICAL HOURS VERIFICATION FORM

Please use this form to document your clinical hours.

This electronic form allows you to document your clinical hours:

Enter your candidate information at the top (it will auto-populate for all experiences)
Complete all required fields (marked with *) for each clinical experience
Use the "Add Clinical Experience" button to add multiple clinical experiences (one for each supervisor)
When complete, use the "Download PDF" or "Print Form" button
For each printed/downloaded form, obtain your clinical supervisor's signature
Sign the attestation section on each printed form
Combine all signed forms into a single file and upload to your online application

NOTE: Signatures can only be added to the printed/downloaded version of this form, not the electronic version.

Full Name:

Email:

Candidate Name:
Candidate Email:
Facility where clinical hours completed:
Start Date:		\| End Date:
Clinical Hours Total:
Clinical Notes:
Supervisor Name:
Supervisor Telephone:
Supervisor's Credentials / Title:
Facility Address:
Facility City:
Facility State:
Facility Zip Code:
Facility Country:

CANDIDATE SECTION