Clinical Supervision Checklist

							     Clinical Supervisor (CS) Applicant Documentation Checklist
                                          IDAPA 16.07.20 subsection 216.02.a through f




Name:
                                                                  Documentation to be submitted to SUD
                                                                   in compliance with IDAPA 16.07.20,
           Documentation/Licensure/Certification                          subsection 216.2.a                         a
                                                            Applicant must meet all requirements of
                                                            IDAPA 16.07.20, subsection 218 prior to
                                                            submitting documentation as a
                                                            clinical supervisor (instructions for documenting 1040
QP Status                                                   hours as a QSUDP is attached.)

IBADCC Certified Clinical Supervisor, or                    Copy of Current Certification.
                                                            Copy of Current Clinical License with Supervisor
Clinical License Supervisor Endorsement from IBOL, or       Endorsement from IBOL
Masters Degree from an accredited, approved, and            Copy of Diploma (note, if applicant is already listed
recognized college or university in health and human        as a QSUDP on the DHW Website, this
Services.                                                   documentation should already be on file at DHW)
                                                            Documentation must be verified by employer for
4 years paid FT Professional Experience                     whom paid experience is being reported.
                                                            Documentation must be verified by employer for
1 year Supervision Experience                               whom paid experience is being reported.
                                                            Verified by QP documentation and employer report of
Demonstrated KSA Competency in providing SUD Tx             applicant experience

2 years experience working with adolescents & family in
SUD Setting - applies if intend to provide CS in OP         Documentation must be verified by employer for
Adolecent Tx Facility                                       whom paid experience is being reported.
                                                            Copy of Certificate of Completion. Applicant has 180
                                                            days from date of employment to complete this
NFATTC CS Training                                          training
                                                            under review - see IDAPA 16.07.20.216.02.f (error
Co-Occuring Disorders                                       in rule needs to be corrected in next rules cycle)


IDAPA Website:
http://adm.idaho.gov/adminrules/rules/idapa16/0720.pdf

DHW QSUDP Website:
http://www.healthandwelfare.idaho.gov/Medical/SubstanceUseDisorders/QualifiedProfessionals/tabid/1004/Default.aspx
(Form created 7-8-10 - updated 11-3-11)