Supervision Form

New Jersey Office of the Attorney General

Division of Consumer Aairs

Orthotics and Prosthetics Board of Examiners

124 Halsey Street, 6th Floor, P.O. Box 45034

Newark, New Jersey 07101

(973) 504-6445

Supervision Form

(To be submitted by Supervisor)

I, _____________________________________________________, New Jersey /License No. ________________ being duly sworn, declare that

Name of Supervisor, (Please Print) Supervisor whose license was active during the supervision.

Pursuant to N.J.A.C. 13:44H-3.6 : ______________________________________________ has completed __________ hours

Name of Applicant (Please Print) Total hours

under my supervision as: (Circle One)

Orthotist; Orthotist Assistant; Prosthetist; Prosthetist Assistant; Prosthetist-Orthotist

Prosthetist - Orthotist Assistant; at ______________________________________________________________________

Name of Facility

__________________________________________________________________________________________________

Address City State Zip Code

Between ____________________________20 ______ and __________________________________20 ______

Applicant _______________________________________________________ , performed the following duties:

Name of Applicant (Student)

_______ hours per week in Orthotics design and evaluation.

_______ hours per week in Orthotics casting, measuring, tting and adjusting.

_______ hours per week on Orthotics manufacture.

_______ hours per week in Clinic Attendance.

_______ hours per week in Prosthetics design and evaluation.

_______ hours per week in Prosthetics casting, measuring, tting and adjusting.

_______ hours per week in prosthetics manufacture.

_______ hours per week in Clinic Attendance.

Pursuant to N.J.A.C. 13:44H-3.6 (i)

Did you initial a daily record of supervised training on the student/applicant daily record?

Yes No

_____________________________________________

Signature of supervisor

Sworn and subscribed to before me this _____________

day of _________________________ , ____________

Month Year

_____________________________________________

Name of Notary Public (please print)

_____________________________________________

Signature of Notary Public

AO-2020-13

Waiver 2020-12

Check the appropriate box:

Orthotist

Orthotist Assistant

Prosthetist

Prosthetist Assistant

Prosthetist-Orthotist

Prosthetist- Orthotist

Assistant

Ax Seal Here

___________________________

My Commission Expires