Brief description of clinical practice activities: Projected start date: _______________ Projected date of completion: _____________ (there Total anticipated number of in-depth cases to be supervised by the CLVT supervisor must be a minimum of five (5) consumers with a wide range of needs and diversities from the beginning initial intake interview to the final case completion): _______________ Total anticipated number of direct observation hours by the CLVT supervisor: _______________ anticipated number of supervisory/technical assistance hours: _______________ Comments: I do hereby affirm that all of the information submitted on this form is true and correct to the best of my knowledge. I further affirm that this provisional contract will be completed with integrity and honesty and in accordance with the Low Vision Therapist Code of Ethics (see Section 6 of the Low Vision Therapist Certification Handbook). Signature of CLVT applicant: _________________________ Date: _____________ I do hereby affirm that all of the information submitted on this form is true and correct to the best of my knowledge. I further affirm that this provisional contract will be completed with integrity and honesty and in accordance with the Low Vision Therapist Code of Ethics. Signature of CLVT supervisor: _________________________ Date: ___________
Brief description of clinical practice activities: Projected start date: _______________ Projected date of completion: _____________ Total anticipated number of in-depth cases to be supervised by the CLVT supervisor (there must be a minimum of five (5) consumers with a wide range of needs and diversities from the beginning initial intake interview to the final case completion): _______________ Total anticipated number of direct observation hours by the CLVT supervisor: _______________ anticipated number of supervisory/technical assistance hours: _______________ Comments: I do hereby affirm that all of the information submitted on this form is true and correct to the best of my knowledge. I further affirm that this provisional contract will be completed with integrity and honesty and in accordance with the Low Vision Therapist Code of Ethics (see Section 6 of the Low Vision Therapist Certification Handbook). Signature of CLVT applicant: _________________________ Date: _____________ I do hereby affirm that all of the information submitted on this form is true and correct to the best of my knowledge. I further affirm that this provisional contract will be completed with integrity and honesty and in accordance with the Low Vision Therapist Code of Ethics. Signature of CLVT supervisor: _________________________ Date: ___________
CLVT%20Offsite%20Supervisior%20Contract.docx