Applicant Clinical Hours Verification Form

Verification of clinical hours form(s) must be submitted by the applicant, including signatures from a current clinical supervisor or co-workers/colleagues who can attest to the applicant’s completion of 3500 hours of direct practice experience in a newborn intensive care unit (NICU). Direct practice experience is defined as evaluation and treatment of high risk infants in a level II, III, or IV NICU as a credentialed OT, PT, or SLP.

The applicant’s verification form(s) will be accepted under the following conditions:

  • If all 3500 direct clinical hours were accrued under one supervisor, one verification form is needed.
    • Hours may only be verified if related to direct treatment in the NICU.
    • Hours spent in feeding and follow-up clinics do not count towards this requirement.
  • If the applicant’s total number of clinical practice hours were accrued at more than one facility, multiple forms must be completed with signatures provided by each applicable supervisor. Download and copy as many forms as needed to complete this requirement.
  • If a current or former supervisor is not available to complete and sign the verification form, two separate forms must be provided by two co-workers able to attest to your completion of 3500 hours as a therapist in the NICU.  Download and copy as many forms as needed to complete this requirement.
  • If total hours were accrued at more than one facility, and supervisor(s) are not available, two separate co-workers from each facility will need to attest to completion of clinical hours. Download and copy as many forms as needed to complete this requirement.

Click here to download verification of clinical hours form.

  1. Open the PDF form, print, complete applicant portion and make copies as needed to complete this requirement.
  2. Obtain signature(s).
  3. Scan, name and upload completed verification form(s) each as a separate file. Please follow the same format to name each file (i.e. Jane_Doe_verification_1).