Proposed Plan of Supervised Clinical Experience

I. Supervisee'sInformation(LSW)

Name: __________________________________________________________________________________

Last Name First Name Middle Initial

Address: ________________________________________________________________________________

Street or P.O. Box City State ZIP Code

Daytime telephone number: ______________________ E-mail address: ______________________________

(include area code and extension)

Licensed Social Worker license number: ___________________________ Active as of: _________________

Date

II. Supervisor’sInformation(LCSW)

Name: __________________________________________________________________________________

Last Name First Name Middle Initial

Business Name: __________________________________________________________________________

Type of business (nonprot, for prot, group, private, etc.)

Business Address: _______________________________________________________________________

Street or P.O. Box City State ZIP Code

Telephone number: _________________________ E-mail address: _________________________________

(include area code and extension)

1. Have you held a License as a Clinical Social Worker (LCSW) in the State of New Jersey for at least

three years? ☐ Yes ☐ No

A. License Number: __________________ B. Year Licensed: _______ C. Expiration Date: _______

2. Please provide the date of completion of the required 20 CE credits pursuant to N.J.A.C.

13:44G-8-1(b)(3)(ii): _____________________________________

(Please include a copy of the certificate with this form)

3. Have any of your licenses or certifications ever been suspended, revoked or restricted in New Jersey or

any state or Jurisdiction? ☐ Yes ☐ No

If “Yes,” please provide details of the suspension or disciplinary action, including dates,

jurisdiction, and copies of any documents setting forth the suspension or disciplinary action.

4. Do you currently supervise any other supervisees (see N.J.A.C.13:44G-8.1(f))?

☐ Yes ☐ No

New Jersey Office of the Attorney General

Division of Consumer Affairs

State Board of Social Work Examiners

124 Halsey Street, 6th Floor, P.O. Box 45033

Newark, New Jersey 07101

(973) 504-6495

www.njconsumeraffairs.gov/sw

Proposed Plan of Supervised Clinical Experience

The Proposed Plan of Supervised Clinical Experience can be submitted prior to the start date of clinical supervision or while the clinical supervision

is ongoing. The purpose of a Proposed Plan of Supervised Clinical Experience is to allow the Board to approve, deny or offer additional

feedback to the supervisee about their supervised clinical experience before the hours have been completed. Please print clearly.

PLEASE NOTE: If you have multiple job titles, employers, or supervisors, you must complete a separate Proposed Plan form for each. Only

one job title is allowed per proposed plan form. If you are working under more than one job title or employer, use separate proposed plan

forms for each.

If “Yes,” provide the names and license numbers of the other individuals and the total number of

supervisees:

Name License Number Name License Number

1. ____________________________________ 2. ____________________________________

3. ____________________________________ 4. ____________________________________

5. ____________________________________ 6. ____________________________________

Out-of-state Supervisors Only

(To be completed only if supervision is taking place outside of New Jersey.)

1. List any and all professional licenses or certifications you hold in any other state, the District of Columbia

or in any other jurisdiction? Please provide a copy of any licenses/certifications.

License type: __________________________ License Number:_____________________

Original issue date: ______________ State or jurisdiction that issued the license or certificate:____________

2. Does your license or certification allow you to supervise in the State in which you are licensed?

If “Yes,” provide a copy of the State law or regulation that allows you to supervise social workers seeking

supervised clinical experience. If listed separately, include a copy of the State law or regulation that lists the

necessary credentials for supervisors, for each jurisdiction where are are an authorized supervisor.

III. SupervisionInformation

1. List the job title held by your supervisee: __________________________________________

This must match the title on the official HR job description included with this form

2. Where will the supervised work take place?

_______________________________________________________________________________

Business Name

_______________________________________________________________________________

Address City State Zip Code

3. Are you employed by the agency or business where the supervised experience will be taking place?

☐ Yes ☐ No

4. If “No,” please attach written consent of the employer to arrange for off-premises supervision (see

N.J.A.C. 13:44G-8.1 (i)).

5. Is there any circumstance that precludes your objective assessment of the applicant?

☐ Yes ☐ No

If “Yes,” please explain on a separate sheet of paper.

☐ Yes ☐ No

5. What are the inclusive dates of supervision? Beginning:

Month/day/year Month/day/year

________ Anticipated Ending: ________

Yes ☐ No

6. Do you agree to maintain weekly supervision notes and co-sign a client contact log which shall

be made available to the Board upon request? ☐

7. Has the applicant read the statutes and regulations of New Jersey that govern the practice of

social work? (N.J.S.A. 45:15BB-1 to N.J.S.A. 45:15BB-13 and N.J.A.C. 13:44G-1.1 to

N.J.A.C. 13:44-15.8)

☐ Yes ☐ No

8. Have you read the pertinent statutes and regulations of New Jersey?

☐

No☐ Yes

9. What are the personal learning objectives for the supervisee?

____________________________________________________________________________

10. Identify the primary clinical duties the supervisee will have: 

____________________________________________________________________________

Yes ☐ No☐

form be submitted by

that supervisor.

11. Are these duties enumerated in the supervisee's job description?

a. If “No,” please be advised that this may imepede the approval process.

12. To your knowledge, will the supervisee have more than one supervisor in the above or another

setting during the inclusive dates? ☐ Yes ☐ No

a. If “Yes,” please advise the supervisee to request that a separate

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The supervisor is required to notify the Board of Social Work Examiners in writing of any changes

in the employment of either the applicant or the supervisor within 30 days.

Certication

I certify that all of the foregoing information provided herein is true and if any information provided by

me is willfully false, I am subject to punishment.

Supervisor’s signature: ________________________________________ Date: __________________

Supervisee’s signature: ________________________________________ Date: __________________

IV. Attachments

Please include the following attachments:

a. Supervisee’s official job description on agency letterhead (the job description should reflect

duties that conform to the definition of “clinical social work services” in N.J.A.C. 13:44G-1.2).

The Board considers a job description "official" if it bears agency letterhead and is issued from

Human Resources as the standard agency job description for your title.

b. Supervisor’s resume or curriculum vitae (include academic, licensure, and certification

information).

c. Supervisor’s certificate of completion of the Board-approved 20-hour CE credits as required

by N.J.A.C. 13:44G-8.1(b)(3)(ii).

d. If the supervision is being rendered in an agency setting by a supervisor who is not employed

by the agency, a letter from the employer on letterhead consenting to outside supervision (see

N.J.A.C. 13:44G-8.1 (i)).