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The Supervision Hours form, specifically known as the University of the State of New York Social Worker Form 6, plays a critical role in the path to becoming a Licensed Master Social Worker (LMSW) in New York. This form, mandated by the State Education Department, is essential for documenting the supervised experience that LMSW applicants must complete to provide clinical social work services, including psychotherapy. To be eligible, applicants must fulfill two thousand client contact hours of post-MSW supervised experience within a time frame of thirty-six months to six years. An important requirement is that this experience must take place under the supervision of a qualified professional, such as a Licensed Clinical Social Worker, licensed psychologist, or a board-certified psychiatrist, who must be employed by the same agency as the LMSW. The process begins with completing the form's first section, which includes personal information and details related to the supervised experience. Applicants must have this form signed off by their supervisor before commencing any supervised hours, and any submission made after the experience is complete will not be reviewed. Additionally, detailed instructions guide both the applicant and supervisor, ensuring compliance with Education Law and Commissioner's Regulations. To maintain accurate records, a psychotherapy log is recommended for tracking hours of practice and supervision. Ultimately, the completion and submission of the Supervision Hours form is a foundational step toward lawful and effective practice in clinical social work.
Supervision Hours Example
The University of the State of New York |
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Social Worker Form 6 |
The State Education Department |
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Office of the Professions |
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Plan for Supervised Experience |
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Division of Professional Licensing Services |
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Application for Licensed Master Social Worker |
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A Licensed Master Social Worker (LMSW) must be registered to practice in New York State and may only provide clinical social work services, including psychotherapy, under the supervision of a Licensed Clinical Social Worker (LCSW), licensed psychologist or licensed physician who is
Prior to starting your supervised experience, you can verify the license status of your proposed supervisor on the Office of the Professions' web site at www.op.nysed.gov/opsearches.htm. This form must be submitted prior to being employed or supervised by your proposed supervisor. This form will not be reviewed if submitted after the supervised experience has been completed.
Applicant Instructions
1.Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensure (FOrm 1). Be sure to sign and date item 9. Use the psychotherapy log to document your hours of practice and supervision.
2.Send the entire form along with a copy of Appendix A to your supervisor and have them complete Section II. Return all pages along with the $10 fee directly to the Office of the Professions at the address at the end of this form.
Section I: Applicant Information
1. Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
2. Birth Date |
Month |
Day
Year
3. Print Name |
Last |
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Middle |
Licensee business address, phone and email address are public information. Failure to indicate business or home on this form for each item will deem it public information.
4.Mailing Address 
Home or 
Business
(You must notify the Department within 30 days of any address or name changes)
Line 1
Line 2
Line 3
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State |
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ZIP Code |
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Province
5.Telephone/Email Address Daytime Phone
Home or 
Business
Area Code |
Phone |
Email Address (please print clearly)
Home or 
Business
6.New York State DMV ID Number (Driver or
(Leave this blank if you do not have a New York State DMV ID Number)
7. New York State LMSW license number
Date LMSW license issued
mo. day yr.
M.S.W. degree date
mo. day |
yr. |
Date registration ends
mo. day |
yr. |
8.You must complete 2,000 client contact hours of
Name of proposed supervisor
Name of setting
Setting address
9.I declare and affirm that the statements made in the foregoing application, including accompanying statements are true, complete and correct. I understand that any false or misleading information in, or in connection with my application may be cause for denial of licensure and may lead to a filing of charges of professional misconduct.
Signature |
Date |
Social Worker Form 6, Page 1 of 2, Revised 11/21
Section II: Supervisor's Verification of Plan for Experience
Instructions to the Supervisor: Read the attached Appendix A and complete all of Section II. Be sure to sign the affidavit and return the entire form directly to the Applicant. By completing Section II, you are certifying that the person named in Section I will receive supervision that meets the requirements as defined in Education Law and the Commissioner's Regulations.
1.Name of the applicant
(see Section I, item 3)
2.Supervisor name
I am licensed and currently registered to practice in New York State as a (check all that apply)
Licensed Clinical Social Worker
Licensed Psychologist
Licensed Physician
Are you ABPN certified in psychiatry?
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No If "yes", ABPN certificate number |
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3.Please identify the employment setting below and attach the operating certificate, NYSED waiver or certificate of incorporation that authorizes the entity to employ LMSWs and LCSWs.
Agency/Practice Name
Type of Setting (check one)
Private practice owned by supervisor (LCSW, Licensed psychologist or psychiatrist)
Professional entity (PLLC, PLLP, P.C.) owned by supervisor (attached consent from SED)
Sole proprietorship or other entity authorized under law (attach certificate of corporation)
Program approved by the New York State Office of Mental Health (OMH), Office for People with Developmental Disabilities (OPWDD),Office of Alcoholism & Substance Abuse Services (OASAS), Office of Children & Family Services (OCFS), Department of Corrections and Community Supervision (DOCCS), Department of Health (DOH), State Office for the Aging, or local social service or mental hygiene district (attach operating certificate)
Elementary, middle, high school or college authorized to provide psychotherapy services to students (attach copy of authorization)
Psychotherapy institute chartered by Board of Regents and authorized to provide psychotherapy to the public (attach copy of Regents Charter)
Other (describe)
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The supervisor must be employed by the same agency as the LMSW and have access to all patient files and records; have responsibility for the assessment, evaluation and treatment of each patient diagnosed and treated by the LMSW practicing under his/her supervision; and each patient must consent to treatment by the supervised LMSW.
Attestation
I hereby certify that I have read Appendix A and that I meet the requirements to supervise a LMSW practicing clinical social work. I understand that the information above will be used to review the plan, all answers given are truthful and accurate to the best of my ability.
Supervisor Signature |
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If you are submitting an initial Form 6, mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY 12201, U.S.A.. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.
Social Worker Form 6, Page 2 of 2, Revised 11/21
Appendix A, Requirements for Supervised Experience LMSW
You must document the completion of three years of
Experience shall consist of not less than 2,000 client contact hours over the course of three years but not to exceed six calendar years. All experience must be obtained in a setting acceptable to the Department after completion of the professional education required for licensure.
Qualified Supervisor
The experience must be supervised by a professional who is licensed and registered to practice as a(n):
●LCSW in New York State or the equivalent as determined by the Department; or
●Psychologist who, at the time of supervision of the applicant, was licensed as a psychologist in the state where supervision occurred, was qualified in psychotherapy as determined by the Department based upon the Department's review of the psychologist's education and training, including but not limited to education and training in psychotherapy obtained through completion of a program in psychotherapy registered pursuant to Part 52 of the Regulations of the Commissioner of Education or a program in psychology accredited by the American Psychological Association; or
●Physician who, at the time of supervision of the applicant, was a diplomate in psychiatry of the American Board of Psychiatry and Neurology, Inc. or had the equivalent training and experience as determined by the Department.
A supervisor who is not licensed in New York State must submit an Approval of Qualifications to Supervise Psychotherapy (Form 4Q) to allow the Department to determine whether the supervisor is qualified in diagnosis, psychotherapy and
A supervisor may not have a familial relationship with the applicant, as such dual relationships may constitute a charge of unprofessional conduct under the Education Law and Regents Rules.
Supervision Sessions
The supervision must consist of 100 or more hours of
●your supervisor must provide the diagnosis and appropriate treatment for each client;
●your cases must be discussed with your supervisor; and
●your supervisor must provide you with oversight and guidance in diagnosis and treating clients.
The supervisor is legally and professionally responsible for the diagnosis and treatment of each client and must have access to all relevant information. It is the responsibility of your employer to provide appropriate supervision as an LMSW may only practice clinical social work under supervision. Any arrangements for
Setting for the Experience
All experience that is completed in New York State must be in a setting that is legally authorized to provide psychotherapy and clinical social work services. An acceptable setting is:
●A professional corporation, professional limited liability partnership or professional limited liability corporation that is authorized to provide services that include psychotherapy;
●A professional service corporation, registered limited liability partnership, or professional service limited liability company authorized to provide services that are within the scope of practice of licensed clinical social work;
●A sole proprietorship owned by a licensee who provides services that are within the scope of his or her profession and services that are within the scope of licensed clinical social work;
●A program or service approved by the New York State Office of Mental Health (OMH), Office for People with Developmental Disabilities (OPWDD), Office Addiction Services and Supports (OASAS), Office of Children & Family Services (OCFS), Department of Corrections and Community Supervision (DOCCS), Department of Health (DOH), State Office for the Aging, or local social service or mental hygiene district;
●A program or facility authorized under federal law, such as the Veterans' Administration, to provide health services including psychotherapy;
●A public elementary, middle or high school authorized by the Education Department to provide school social work services as defined in Part
●An entity defined as exempt from the licensing requirements under New York Law* or otherwise authorized under New York Law of the laws of the jurisdiction in which the entity is located to provide services, including psychotherapy.
In New York State, a general business corporation or
It is your responsibility to practice only under a qualified supervisor and in an authorized setting. You should review the supervisor qualifications and acceptable experience with an employer before you accept a position practicing clinical social work.
Licensed Master Social Worker Appendix A, Revised 11/21
Psychotherapy Log |
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Use this weekly log to document the applicant's hours of practice and supervision for Licensed Clinical Social Work. All pages |
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of this log must be retained by the supervisor and submitted upon request of the Department. Please copy this log as needed. |
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Week starting date for
psychotherapy
(mo./day/yr.)
Client Contact
Hours/Week*
Applicant Initials
Supervision Type
(Individual or Group)**
Supervision
Hours/Week**
Supervisor Initials
*Client contact hour = 45 minutes of psychotherapy (shorter sessions may be combined) **Supervision = at least 100 hours of in person supervision given by the attesting supervisor
Social Worker Psychotherapy Log, Revised 11/21
File Breakdown
| Fact Name | Description |
|---|---|
| Governing Law | The Supervision Hours form is governed by the Education Law and the Commissioner's Regulations of New York State. |
| Supervision Requirement | A Licensed Master Social Worker (LMSW) must practice under the supervision of a Licensed Clinical Social Worker (LCSW), licensed psychologist, or board-certified psychiatrist. |
| Client Contact Hours | Applicants must complete 2,000 client contact hours of supervised experience within a minimum of 36 months and a maximum of 6 years. |
| Form Submission Timing | This form must be submitted before beginning the supervised experience; post-experience submissions will not be reviewed. |
| Supervisor Verification | The supervisor must verify that they will provide the necessary supervision, ensuring that it meets the legislative requirements. |
| Fee Requirement | A $10 fee must accompany the submission of the Supervision Hours form to the Office of the Professions. |
| Documentation | The applicant must keep a psychotherapy log documenting their supervised hours and submit it upon request by the Department. |
Guide to Using Supervision Hours
Completing the Supervision Hours form is an important step in your journey to becoming a Licensed Master Social Worker. This process allows you to document and validate your supervised experience. Follow these steps carefully to ensure your form is filled out correctly.
- Complete Section I: Fill in your information accurately. In item 3, make sure your name matches the Application for Licensure. Also, remember to sign and date item 9.
- Document Hours: Use the psychotherapy log to keep track of your practice and supervision hours.
- Send to Supervisor: Send the entire form and a copy of Appendix A to your proposed supervisor. They will need to fill out Section II.
- Return the Form: Once your supervisor has completed Section II, gather all pages and send them, along with the $10 fee, to the Office of the Professions at the address provided at the end of the form.
Get Answers on Supervision Hours
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What is the purpose of the Supervision Hours form?
The Supervision Hours form is required for Licensed Master Social Workers (LMSWs) seeking to document their 2,000 client contact hours of post-graduate supervised experience. This form must be completed prior to starting supervised experience in order to ensure compliance with New York State regulations regarding clinical social work services.
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Who qualifies as a supervisor for the LMSW?
A qualified supervisor can be a Licensed Clinical Social Worker (LCSW), a licensed psychologist with the necessary qualifications in psychotherapy, or a board-certified physician specializing in psychiatry. It is essential that the supervisor meets all requirements outlined by the New York State Education Department.
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When do I need to submit the Supervision Hours form?
The Supervision Hours form must be submitted before you begin your supervised experience. Submitting the form afterwards will lead to rejection, and you will not be able to use those hours for your licensure application.
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What documents need to be sent along with the Supervision Hours form?
Along with the completed Supervision Hours form, a copy of Appendix A must be provided to your supervisor for their verification. After they complete their section, they will return the entire form to you for submission to the Office of the Professions.
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How do I document my supervision hours?
Supervision hours should be documented using the psychotherapy log provided with the Supervision Hours form. This log records client contact hours and supervision details. Ensure that all pages are retained by the supervisor and can be provided upon request by the Department.
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What is included under client contact hours?
Client contact hours refer to any time spent in psychotherapy with clients. Each hour is typically defined as 45 minutes of direct service. Shorter sessions can be combined for documentation purposes. Accumulating these hours is crucial for licensure.
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What if I move or change my name during the supervised experience?
You must inform the Department of any changes to your name or mailing address within 30 days. It is important that your contact information remains up to date to avoid any delays in communication regarding your application and licensure process.
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Is my supervision confidential?
Yes, confidentiality is a priority. However, discuss how information will be handled if there is third-party supervision involved. This ensures clarity for both clients and supervisors about how their information is managed and reviewed.
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What kind of setting is acceptable for my supervised experience?
The setting for your supervised experience must be legally authorized to provide clinical social work services. Acceptable environments include professional practices, authorized programs under relevant state departments, and educational institutions providing psychotherapy services.
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Can I employ my own supervisor?
No, you cannot employ or contract with your supervisor. Your supervisor must be employed by the same agency as you and should be responsible for overseeing your clinical practice and ensuring compliance with strength of supervision.
Common mistakes
Completing the Supervision Hours form is critical for future Licensed Master Social Workers (LMSWs). However, many applicants encounter common pitfalls that can lead to delays or even rejection of their forms. One frequent mistake is neglecting to use the name exactly as it appears on their Application for Licensure. This seemingly small error can cause confusion and complicate the verification process.
Another common issue occurs when applicants fail to include their Social Security Number or leave it blank when they do not have one. Although the instructions specify that it’s acceptable to leave this blank, applicants should ensure they are aware of other required fields to prevent unnecessary delays.
Some people mistakenly submit the completed form after their supervised experience has concluded. The regulations clearly state that the form must be submitted prior to starting the supervision. Getting this order wrong can render the application invalid and require resubmission.
Additionally, failing to provide complete contact information can create further complications. Each item must be filled out accurately, specifying whether the provided address is a home or business address. If this detail is omitted, the application may be flagged as incomplete.
It's also essential to pay attention to the payment instructions. Some applicants overlook the requirement of including the $10 fee with their submission, leading to automatic rejections. Therefore, it’s wise to double-check that this payment is included and that cash is not sent, as that is explicitly related.
Furthermore, candidates often overlook the importance of ensuring that their proposed supervisor meets all qualifications. Supervisors must be either a licensed clinical social worker, a psychologist, or a licensed physician. Not verifying these qualifications beforehand can result in unnecessary complications later on.
Finally, many applicants do not keep copies of their submissions. While it might seem unnecessary, having a personal record of what was sent can prove invaluable. If issues arise or questions come up regarding your submission, having original documents at hand can simplify the troubleshooting process.
Documents used along the form
When pursuing licensure as a Licensed Master Social Worker (LMSW) in New York, several accompanying documents are often necessary alongside the Supervision Hours form. These documents help facilitate the licensing process by ensuring all requirements and qualifications are accurately documented and verified. Here is a list of relevant forms and documents that may be used in conjunction with the Supervision Hours form.
- Application for Licensed Master Social Worker (Form 1): This application is the foundational step for prospective LMSWs, where personal and educational details are provided to initiate the licensure process.
- Psychotherapy Log: A crucial tracking tool for documenting client contact hours and supervision sessions. This log helps maintain a clear record of the hours worked towards licensing requirements.
- Approval of Qualifications to Supervise Psychotherapy (Form 4Q): If a prospective supervisor is not licensed in New York State, this form is necessary to establish their qualifications to provide supervision for an LMSW.
- Appendix A: Requirements for Supervised Experience: This document outlines essential details about the type of supervised experience required, including minimum hours and acceptable settings for practice.
- Proof of Supervision Agreement: A written document setting the terms and conditions of supervision between the LMSW, the supervisor, and the employing agency, ensuring all parties are aware of their responsibilities.
- Supervisor's Credentials Verification: A form that affirms the credentials of the proposed supervisor, ensuring they meet all licensing requirements as outlined by the state.
- Setting Authorization Documentation: This includes certificates or waivers indicating that the practice setting is authorized to employ LMSWs and provide psychotherapy services.
- Employer Notification of Changes Form: A form used by the LMSW to inform the New York State Education Department of any changes in employment status, ensuring the records are up-to-date.
Proper management of these documents is essential for a smooth licensure application process. Each form plays a significant role in verifying qualifications and ensuring compliance with state regulations. Keep careful records and maintain open communication with supervisors and employers to facilitate your progress towards becoming a Licensed Master Social Worker.
Similar forms
The Supervision Hours form, a vital document for those pursuing licensure as a Licensed Master Social Worker (LMSW) in New York State, shares similarities with several other important documents. Here’s a breakdown of six documents that are akin to the Supervision Hours form:
- Application for Licensed Master Social Worker: Both documents require detailed personal information, including your name and license number. They are essential for verifying your qualifications for licensure.
- Psychotherapy Log: This log accounts for the hours of practice and supervision similar to how the Supervision Hours form tracks your supervised experience. Both documents ensure that you meet the required hours necessary for licensure.
- Approval of Qualifications to Supervise Psychotherapy (Form 4Q): Like the Supervision Hours form, this form confirms the qualifications of supervisors. Both protect the interests of applicants by ensuring that the supervisors meet specific criteria recognized by the state.
- Certification of Supervised Experience: Comparable to the Supervision Hours form, this certification validates that a candidate has undergone the necessary supervised clinical training. Both affirm the experience gained under applicable supervision.
- Employment Verification Form: Similar to the Supervision Hours form, this document verifies employment details and settings. It is crucial for establishing that the candidate has operated within authorized and compliant environments.
- Client Consent Forms: These forms ensure that clients are aware of and agree to treatment by a supervised LMSW. Just as the Supervision Hours form is structured to track compliance with state regulations, client consent forms ensure ethical practices in treatment.
Each of these documents plays a key role in guiding prospective LMSWs through the licensure process while safeguarding both the professionals and the clients they serve.
Dos and Don'ts
When completing the Supervision Hours form, adhering to specific guidelines can facilitate a smoother process. Here are ten things to remember:
- Do: Enter your name exactly as it appears on your licensure application.
- Don't: Submit the form without verifying your supervisor's license status on the Office of the Professions website.
- Do: Include your Social Security Number only if you have one; leave it blank otherwise.
- Don't: Forget to sign and date the application before submission.
- Do: Use the psychotherapy log to accurately document client contact hours and supervision details.
- Don't: Omit any information on the employment setting; this is crucial for approval.
- Do: Send the entire form along with a copy of Appendix A to your supervisor for their completion.
- Don't: Neglect to check the qualifications of your proposed supervisor before beginning your supervised experience.
- Do: Include a correct mailing address, indicating whether it’s for home or business.
- Don't: Forget to remit the $10 fee with your submission; cash is not accepted.
Following these guidelines ensures that your application is processed efficiently and without unnecessary delays.
Misconceptions
Misconceptions about the Supervision Hours form can lead to confusion for aspiring LMSWs. Here are seven common myths, debunked for clarity.
- Submitting Late Is No Big Deal: Many believe it’s acceptable to submit the Supervision Hours form after their supervised experience has ended. In reality, this form must be submitted beforehand; late submissions may lead to disqualification.
- Choosing Any Supervisor Is Fine: Some think any licensed professional can supervise their experience. However, supervision must come from specific professionals like a Licensed Clinical Social Worker (LCSW), licensed psychologist, or a board-certified psychiatrist, as mandated by law.
- Providing Clinical Services Alone is Enough: There is a misconception that simply providing clinical services is adequate to fulfill the requirements. In truth, LMSWs must document their hours properly, ensuring compliance with guidelines set forth by the State Education Department.
- Supervision Doesn't Need to Be Documented: Many applicants mistakenly assume that verbal agreements or informal notes are sufficient. Accurate and thorough documentation of supervision hours is essential and harmful gaps may jeopardize licensure.
- Emailing the Form is Acceptable: Some applicants believe that sending the form electronically suffices. However, the form must be mailed physically to the Office of the Professions; electronic submission is not accepted.
- Focus Solely on Supervision Hours: While documenting hours is crucial, applicants often overlook the need to ensure their supervisor meets specific qualifications as outlined in the regulations. All supervisors must be qualified and cannot have a familial relationship with the applicant.
- The Employer Takes Care of Everything: There's a belief that once hired, the employer will manage the application process. However, it is ultimately the applicant's responsibility to understand and meet all requirements for licensure, including the supervision aspect.
Understanding these misconceptions helps ensure that candidates for licensure follow the proper procedures and avoid unnecessary setbacks.
Key takeaways
Here are some key points to remember when filling out and using the Supervision Hours form:
- Complete Section I carefully: Make sure to enter your name as it appears on your licensure application and sign where indicated.
- Supervisor verification: After you fill out Section I, send the form to your supervisor for them to complete Section II.
- Submit on time: This form must be submitted before you begin your supervised experience to avoid complications.
- Use the psychotherapy log: Keep track of your hours of practice and supervision using the provided log format.
- Verification of supervisor's license: Check your supervisor's license status on the Office of the Professions' website before submitting the form.
- Employment restrictions: Remember, as an LMSW, you cannot employ or contract with your own supervisor.
- Document client contact hours: You need to complete 2,000 hours over three to six years under qualified supervision.
- Eligible supervisors: Ensure your supervisor is an LCSW, licensed psychologist, or a board-certified psychiatrist.
- Specific settings required: Your supervised experience must occur in an authorized and acceptable setting according to New York State regulations.
- Informed consent: Clients must be informed about your supervision and consent to receive treatment from you.
By keeping these points in mind, you can navigate the Supervision Hours form process smoothly and ensure compliance with all guidelines.