Remediation Plan

FELLOW REMEDIATION PLAN

Date of Meeting:

Fellow:

Supervisors present:

Date for follow up meeting:

 Mark /describe the pertinent competency domain(s) affected:

__ Assessment ____________________________________________________

__ Consultation ___________________________________________________

__ Intervention ____________________________________________________

__ Advanced Knowledge ___________________________________________

__ Research _______________________________________________________

__ Licensure _______________________________________________________

__ Other (specify) _______________________________________________________

Date the problem(s) were first addressed with the fellow:

Steps taken by the fellow to rectify these problem(s): _______________________________________________________________________

Steps employed by the supervisor(s) to rectify these problem(s): _______________________________________________________________________

Planned course of action: _______________________________________________________________________

I acknowledged that the abovementioned issues have been discussed with me and that a remediation plan has been established for these purposes.

_______________________________________________________________________

Neuropsychology fellow print name/signature (Date)

________________________________________________________________________ Neuropsychology supervisor(s) print name(s)/signature(s) (Date)