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GENERAL SUPERVISION EVALUATION FORM FOR …
OBLADC form 208 11/2012 1 GENERAL SUPERVISION EVALUATION form FOR DRUG AND ALCOHOL LICENSURE/ certification eligibility LADC - Typically 50 completed hours of educational SUPERVISION / 2000 completed hours of practice/work hours under SUPERVISION CADC - Typically 100 completed hours of educational SUPERVISION / 4000 completed hours of practice/work hours under SUPERVISION LADC/MH - Typically 50 completed hours of educational SUPERVISION / 2000 completed hours of practice/work hours under SUPERVISION PARTIAL SUPERVISION (Due to a change in status, change of SUPERVISION , change of employment): Number of completed hours of SUPERVISION this EVALUATION :_____ Hours to present date: _____ SUPERVISEE Other name(s) under which evaluations have been submitted Home Address - Street/City/State/Zip Home E-Mail Home Phone ( ) Employing Agency Position Position is: Full Time Part-Time: Number of hours per week: Agency Address Street/City/State/Zip Agency E-Mail Agency Phone ( ) SUPERVISOR License Number Job Title Agency Phone ( ) Employing Agency Agency E-Mail Agency Address Street/City/State/Zip PERIOD OF SUPERVISION : From _____ To _____ (Month/Day/Year) (Month/Day/Year) Total hours of Individual* & Group** SUPERVISION this EVALUATION : Total ho
OBLADC Form 208 11/2012 1 GENERAL SUPERVISION EVALUATION FORM FOR DRUG AND ALCOHOL LICENSURE/CERTIFICATION ELIGIBILITY LADC - Typically 50 completed hours of educational supervision / 2000 completed hours of practice/work hours under supervision CADC - Typically 100 completed hours of educational supervision / …
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