Click here to download a copy of Certification Appendix P-3D
REQUEST FOR ASSOCIATE SUPERVISOR STATUS
The report of this meeting includes:
1. Evaluation of the applicant’s written materials.
2. An Appendix 8 (Certification Manual) signed by the Program Manager or designee attesting meeting formal requirements.
3. Summary of the interview (describing the interaction of the applicant with the subcommittee).
4.Evaluation of the following professional competencies: (Certification as an Associate Supervisor requires a “satisfactory” rating in each of these four categories.)
- Supervisory Competence,
- Conceptual Competence,
- Collegial Competence, and
- Pastoral competence
5. Clear indication whether request for status granted or denied.
6. Names of subcommittee members.
7. Commission actions – See ACPE 2016 Certification Manual, Associate Supervisor Certification
ASSOCIATION FOR CLINICAL PASTORAL EDUCATION, INC.
CERTIFICATION COMMISSION
REPORT OF COMMISSION ACTION
SUPERVISORY CANDIDATE:
DATE:
ADDRESS:
REGION:
PRESENTER:
SUPERVISORY CANDIDATE REQUEST: ASSOCIATE SUPERVISOR
COMMISSION ACTION: ____ GRANT ____ DENY ____ SUSPEND SUPERVISORY CANDIDATE STATUS
1. BRIEFLY EVALUATE THE SUPERVISORY CANDIDATE’S WRITTEN MATERIALS:
2. SUMMARIZE THE INTERVIEW: (Describe the interaction of the candidate with the subcommittee.)
3. HAS THE SUPERVISORY CANDIDATE MAINTAINED FAITH GROUP ENDORSEMENT? ____ Yes ____No
4. EVALUATE THE FOLLOWING PROFESSIONAL COMPETENCIES:
4.1. SUPERVISORY COMPETENCE: _____ Satisfactory _____ Unsatisfactory
Demonstrated ability to plan and implement a program of CPE and effectively assist students in meeting the objectives and expected outcomes of CPE:
408.1 demonstrates a broadly understood and applied pastoral identity which is congruent with one’s pastoral practice ____ Met ___Unmet
408.2 demonstrates the ability to supervise student learning in individual and group ____ Met ___Unmet.
408.3 demonstrates the ability to plan, organize and implement a unit of CPE Level I/Level II __ Met __Unmet
408.4 demonstrates the ability to implement one’s theory of supervision ____ Met ___Unmet
408.5 critiques one’s supervisory methodology based on feedback. ____ Met ___Unmet
408.6 demonstrates the development of an effective supervisory relationship ____ Met ___Unmet
4.2. CONCEPTUAL COMPETENCE: _____ Satisfactory _____ Unsatisfactory
Demonstrated ability to articulate supervisory work with specificity, bringing theoretical perspectives to supervisory events and exemplifying preferred theory through references to supervisory functioning:
409.1 is familiar with diverse conceptual frameworks in pastoral theology, personality theory, learning theory, group process theory, cultural anthropology, social organization, and change. ____ Met ___Unmet
409.2 is able to articulate and integrate one’s theory, skill and art of supervision. ____ Met ___Unmet
409.3 the ACPE standards and the history of CPE. ____ Met ___Unmet
409.4 is able to affirm and/or modify one’s supervision in response to self-reflection, self-evaluation and the consultation of one’s supervisors, peers and students____ Met ___Unmet
4.3. PASTORAL COMPETENCE: _____ Satisfactory _____ Unsatisfactory
Continues to demonstrate pastoral competence as defined in Standard 410/404.
Demonstrates:
404.1 personal integrity and pastoral identity. ____ Met ___Unmet
404.2 emotional and spiritual maturity. ____ Met ___Unmet
404.3 ability to form meaningful pastoral relationships. ____ Met ___Unmet
404.4 ability to self-supervise own on-going practice ____ Met ___Unmet
404.5 ability to refine one’s professional identity as a clinical pastoral educator. ____ Met ___Unmet
404.6 ability to explicate how one’s personal history and culture affects professional and personal
identity, pastoral practice, the supervisory relationship and student learning.____ Met ___Unmet
4.4. COLLEGIAL COMPETENCE: _____ Satisfactory _____ Unsatisfactory
Demonstrated capacity and motivation to use peer relationships regularly for consultation, support, clarification, and challenge in practice and development of the art of supervision.
408.7 demonstrates collegial competence. ____ Met ___Unmet
5. FURTHER ADDRESS ITEMS IN #4 AS NEEDED.
6. Suspend the Supervisory Candidate status if Supervisory Candidate-level competencies are clearly being unmet and/or if the students are being harmed. If such action is being considered, the committee must confer with the Certification Commission Chair prior to making a decision.
6.1. Reason(s) for taking such action:
6.2. List the competency concerns to be addressed and the materials to be included
7. RECOMMENDATIONS FOR FURTHER PROFESSIONAL DEVELOPMENT:
8. EXCEPTIONAL APPEARANCE:
Candidate excelled in their appearance before the Commission subcommittee ________________.
SUBCOMMITTEE MEMBERS:
1._________________________________ 4.________________________________
2._________________________________ 5.________________________________
3. ________________________________
_______________________________________________________________________
Name: (Certification Chair):