MISSOURI SUBSTANCE ABUSE COUNSELORS' by B7BptW86

VIEWS: 2 PAGES: 20

									Missouri Substance Abuse Professional
Credentialing Board
(573) 751-9211                    www.msapcb.com                P.O. Box 1250
                                  email: help@msapcb.com        Jefferson City, MO 65102-1250


                    Criteria for Certified Reciprocal Prevention Specialist (CRPS)

           Certified Reciprocal Prevention Specialist
               Completion of Substance Abuse Prevention Specialist Training (SAPST) –
                   Contact ACT Missouri at 573-635-6669 for information about attending this
                   training.
               HS Diploma/GED & 4000 hours prevention work experience within last 10
                   years or
               Bachelor Degree (Higher) & 2000 hours prevention work experience within
                   last 10 years
               Degree must be from a college or university found in the US Dept. of
                   Education’s database of accredited schools. The database can be found at
                   http://ope.ed.gov/accreditation.
               300 Performing Hours of Supervised Practicum in the 5 IC&RC prevention
                   domains with a minimum of 10 performing hours in each domain
               100 Total Contact Hours of Education relating to the 5 IC&RC prevention
                   domains. Within the 100 hours, there are some specific requirements
                   including:
                        6 contact hours of live ethics (not online or home study)
                        50 contact hours of Alcohol, Tobacco, and Other Drug prevention
                           training
                        20 hours of the 100 hours must have been obtained in the 12
                           months prior to applying
               Pass the IC&RC International Prevention Specialist Examination




     Revised July 12 CRPS Application                                                           1
               CHECK LIST FOR CRPS APPLICATION

1. You have completely filled out the application.
2. You have signed the Code of Ethical Practice/Professional Conduct and Authorization &
    Release.
3. You have filled out the Family Care Safety Registry Worker Registration Form and included
    the form with your application.
4. You have submitted the $335.00 with this application or have provided your credit card
    information on page 7 of this application.
5. The appropriate person has completed, signed, and had notarized the Prevention Professional
    Employment Verification Form and mailed this form directly to the MSAPCB.
6. Official Job Descriptions were attached to the Prevention Professional Employment
    Verification Form (s).
7. The appropriate High School/GED or official college transcripts were sent.
8. The appropriate certificates of completion are attached documenting the total hours of
    education needed for the CRPS.
9. The supervised practicum form has been completed by a MSAPCB Qualified Prevention
    Supervisor. The form documents at least 300 total hours of practicum hours with at least a
    minimum of 10 hours in each of the 5 performance domains.
10. If applicant does not hold the Missouri Substance Abuse Prevention Associate (MSAPA)
    credential, a copy of the certificate showing completion of the Substance Abuse Prevention
    Specialist Training (SAPST) must be included with the application. (Contact ACT Missouri at
    573-635-6669 for information about attending this training)




  Revised July 12 CRPS Application                                                           2
                                                DEFINITIONS

A. CONTACT HOURS of EDUCATION/TRAINING is defined as workshops, seminars, institutes,
college/university courses, on-line or home study as approved by the MSAPCB, and in-services. One (1)
contact hour of education is equal to sixty (60) minutes of continuous instruction. 15 contact hours are given for
each college credit. Therefore, a college course of three (3) credits is equal to forty-five (45) contact hours.

In order to be considered a valid training experience for the purpose of credentialing, all contact hours must be
related to the knowledge and skill base associated with the five prevention performance domains of: Planning
and Evaluation; Education and Skill Development; Community Organization; Public Policy and Environmental
Change ; and Professional Growth and Responsibility.

All education/training taking place outside the applicant's place of employment must be documented through
proof of attendance including original, official transcripts (not issued to the student or copied) from an
accredited college, letters and/or certificates of training completion. Supporting documentation in the form of
brochures, flyers, syllabus, course description, etc. is also required to review content for acceptability.

All education/training taking place within the applicant's place of employment must be documented by title, date
and length of presentation, as well as the name and title of presenter. The employee’s supervisor who attests the
training took place and the employee was a participant in the entire training must verify the training.


B.     APPLICABLE WORK EXPERIENCE is defined as supervised work experience in Alcohol, Tobacco,
and Other Drug (ATOD) prevention related positions with job duties that are specific to the five performance
domains of: Planning and Evaluation; Education and Skill Development; Community Organization; Public
Policy and Environmental Change; and Professional Growth and Responsibility. Experience as a volunteer,
intern, and/or payment of a stipend qualifies as employment if the same work is performed that a paid employee
would perform.

All qualifying work experience must have been accrued during the ten (10) years immediately prior to
application being made. The maximum hours that can be accrued are one hundred and sixty seven (167) per
month or two thousand (2,000) per year.

Work experience must be verified by an employment verification form from the agency(s) in which the
applicant has been employed.


C. SUPERVISED PRACTICUM IN THE 5 PERFORMANCE DOMAINS is defined as providing the 5
performance domains while under supervision.

The supervision of the experience of providing the 5 performance domains may take place within an academic
setting and/or within a supervised work setting. The goal is to receive supervised experience in all of the 5
performance domains. Applicants must complete a minimum of 10 hours performing each of the 5 performance
domains with a total supervised practicum of 300 hours.

The practicum hours must be signed by a MSAPCB Qualified Prevention Supervisor.




      Revised July 12 CRPS Application                                                                          3
Missouri Substance Abuse Professional
Credentialing Board
(573) 751-9211                       www.msapcb.com                   P.O. Box 1250
                                     email: help@msapcb.com           Jefferson City, MO 65102-1250




                                      Application Instructions:

   1. Requirements to receive this credential are subject to change without notice. Please make sure you are
       submitting the current application packet. If you are unsure, contact the MSAPCB office.
   2. The application must be typed or neatly printed.
   3. If you do not already hold the Missouri Substance Abuse Prevention Associate Credential, you must
       submit a copy of the Substance Abuse Prevention Specialist Training (SAPST) completion certificate.
       (Contact ACT Missouri at 573-635-6669 for information about attending this training)
   4. Please keep a copy of all materials submitted for your records.
   5. FEES: The total CRPS Fee is $335.00. (This includes the application packet, processing, background
       screening, and first time test fees) You may pay by check, money order, or by providing credit card
       information on page 7 of the application packet.
   6. Please be advised that should your application be reviewed and additional information is requested, you
       will have 90 days to provide the requested information. Failure to do so will result in your application
       expiring without being approved.
   7. All fees are non-refundable. If your application is denied or expires, fees will not be refunded.
   8. If your application is denied, you may contact the MSAPCB office staff for instructions on how to
       appeal the denial of your application.
   9. All materials submitted to the MSAPCB office become property of the MSAPCB.
   10. The applicant must currently reside and/or be employed in the State of Missouri at least 51% of the time.
       The only exception to this is applicants living and working in a state that is not a member of the
       International Certification and Reciprocity Consortium.
   11. Please remember that it is your responsibility to keep the MSAPCB office informed of any personal
       informational changes such as address and phone number changes. If you fail to notify us of changes,
       you will be responsible for any material that is mailed to the wrong address and will have to pay a fee to
       have the material sent again.
   12. Please mail your application to us. Please do not fax your application.




     Revised July 12 CRPS Application                                                                          4
Missouri Substance Abuse Professional
Credentialing Board
(573) 751-9211                       www.msapcb.com                   P.O. Box 1250
                                     email: help@msapcb.com           Jefferson City, MO 65102-1250




                                         Useful Information:

    1. If at any time during the application process, a question arises regarding an applicant’s moral character,
       reputation for honesty, integrity, or professionalism, the Board may deny the application at that time or
       place the application on hold until an investigation has been done and a decision made regarding the
       question brought up.
    2. Once your application has been accepted and has final approval, you will receive a letter from our office
       with further instructions on how to continue the application/testing process. With this letter, you will
       also receive a testing Candidate Guide. This guide provides you sample questions for the exam. In
       addition, additional study materials can be purchased. The company that sells a study guide is listed on
       our web site www.msapcb.com under the “Items for sale” link. The company name is ReadyToTest.
       PLEASE NOTE: Once your application is reviewed and complete, you will be given 30 days to
       contact the MSAPCB office to pre-register for testing. Upon contacting the office for pre-
       registering, you will then be given 90 days to take the exam. So, in total, from the time your
       application is reviewed and complete, you will have 120 days to take the exam.
    3. The CRPS credential is a reciprocal credential with other IC&RC member boards that offer the
       prevention credential. You can contact the MSAPCB office for more information on reciprocity.




      Revised July 12 CRPS Application                                                                         5
                                   Important Notice To Applicants

According to Missouri Substance Abuse Professional Credentialing Board (MSAPCB) Policies and Procedures,
the following rules apply to those seeking a MSAPCB credential.

   1.    No individual currently under any type of court supervision can apply for a MSAPCB credential.
         Please wait until you are completely free from court supervision before applying.
   2.    The following items disqualify an individual from ever being credentialed with the MSAPCB:
         A. Is listed on the Department of Mental Health disqualification registry
         B. Is listed on the employee disqualification list of the Dept. Health and Senior Services or Dept. of
              Social Services
         C. A person who has been convicted of, found guilty to, plead guilty to or nolo contendere to any of
              the following crimes. The crimes listed will only disqualify an applicant if the crime was a felony.
                  a. 1st/2nd degree murder                     aa. Failure to report abuse & neglect to DSS
                  b. Voluntary manslaughter                    bb. Any equivalent felony offense
                  c. Involuntary manslaughter                  cc. Forcible sodomy
                        st
                  d. 1 /2nd degree assault                     dd. Deviate sexual assault
                  e. Assault while on school property          ee. Sexual abuse
                  f. Unlawful endangerment of another          ff. Abuse of a child
                  g. Sexual assault                            gg. 1st/2nd degree pharmacy robbery
                  h. Tampering with a judicial officer         hh. Arson in the 1st/2nd degree
                  i. Kidnapping                                ii. Incest
                  j. Felonious restraint                       jj. Causing catastrophe
                  k. False imprisonment                        kk. 1st degree burglary
                  l. Interference with custody
                  m. Parental kidnapping
                  n. Child abduction
                  o. Elder abuse in 1st/2nd degree
                  p. Harassment
                  q. Stalking
                  r. Forcible rape
                  s. 1st/2nd degree statutory rape
                  t. 1st/2nd degree assault of a law enforcement officer
                  u. 1st/2nd degree statutory sodomy
                  v. 1st/2nd degree child molestation
                  w. 1st degree sexual misconduct
                  x. Endangering the welfare of a child
                  y. Robbery in the 1st/2nd degree
                  z. Felony count of invasion of privacy
         D. Any crime against a minor not listed above
   3.    If an individual has applied for and been given an exemption from the Department of Mental Health,
         the individual may apply for a MSAPCB credential. Please send in proof of exemption with your
         application.




        Revised July 12 CRPS Application                                                                        6
                                 APPLICATION
                                               FOR


      Certified Reciprocal Prevention Specialist (CRPS)

                      Appropriate fee must be submitted with application.


                      MISSOURI SUBSTANCE ABUSE PROFESSIONAL
                               CREDENTIALING BOARD
                                    P.O. BOX 1250
                         JEFFERSON CITY, MISSOURI 65102-1250

                                      TELEPHONE: (573) 751-9211

                                      WEB SITE: www.msapcb.com

                                       EMAIL: help@msapcb.com



Please Mark Credit Card Type:
    1. Visa          _____________
    2. MC            _____________
    3. Discover      _____________

CC Expiration Date:   _____/_______

Credit Card #: __________-______________-______________-____________

Credit Card 3 Digit Verification Code: ________________________________




     Revised July 12 CRPS Application                                       7
                      THIS APPLICATION MUST BE TYPED OR PRINTED NEATLY
                            All Applications Become the Property of MSAPCB

Please check if you are:         ______ New Applicant              ______ Upgrade Applicant


Applicant’s Name: ___________________________________________________________________________
                         First                            Middle                      Last            Sir Name

___________________________________________________________________________________________________________
              Maiden                                            Other Names Used
Current Home Address: _____________________________________________________________________________
                                 Street/PO Box                                        Apt. #

______________________________________________________________________________________________________________________
        City                           State                   Zip                     County

Home Telephone: ________/_______________                              SSN: __________-________-______________

Work Telephone: ________/_______________, Ext. ________ Cell Number: ________/_______________

E-mail Address: _____________________________________________________________________________

SEX: ____M      ____F                    BIRTH DATE: _____/_____/____________

Are you currently or have you been credentialed or licensed as a Prevention Professional by any other state or
organization? ______Yes ______No
If yes, which state/organization and when? _____________________________________________________________
What is the type of credential/license held with the other state/organization?
_________________________________________________________________________________________________



Have you ever been ARRESTED and/or CONVICTED of a felony? ____Yes ____No
If yes, please go to the www.msapcb.com website, print off the “Felony Offense Form”, fill out the form and submit
with your application. If you were convicted of a felony listed under 2C on page 6 of this application, you may not
apply for this credential without an exemption from the Department of Mental Health.


Have you ever knowingly been contacted by a Division of Family Services employee regarding a CHILD ABUSE and/or
CHILD NEGLECT incident involving you? ______Yes ______No
If yes, please go to the www.msapcb.com website, print off the “Child Abuse/Neglect Statement”, fill out the form and
submit with your application. In addition, please contact the Division of Family Services at 573-751-2330 and request
a report of the incident to include with this application.




      Revised July 12 CRPS Application                                                                                8
                                      Education/Degree Information
Name of High School _______________________________________________________________________________

Dates of Attendance from_________________ to _________________Did you graduate? _________________________

Location of High School _____________________________________________________________________________

G.E.D __________ Date _______/_______/________ Where Issued _________________________________________

College and University (undergraduate, graduate, professional)
                                   FROM            TO          TOTAL                 DEGREE AND DATE
                                                             SEMESTER    MAJOR     RECEIVED AND/OR # OF
   NAME AND LOCATION             MO     YR    MO        YR     HOURS    SUBJECTS      CREDIT HOURS

Name ______________________

Location

Name ______________________

Location

Name ______________________

Location

Please have official transcript(s) of any applicable course work to be evaluated for the education
requirement sent directly to the MSAPCB Board office. Student copies or photocopies will not be
accepted.




      Revised July 12 CRPS Application                                                                  9
APPLICABLE WORK EXPERIENCE
Describe ONLY your applicable Work Experience below, beginning with your most recent position. If you have held
more than one position with an organization, please list each position separately. Make additional copies of this page if
necessary to document all applicable work experience. Work experience will be prorated if not working full time in an
applicable position. Final determination of the acceptability of work experience shall be at the discretion of the
MSAPCB.
1. Where Do You Currently Work?                          Do you currently work in a CSTAR Program?                             YES      NO
Name of Employer:


Mailing Address of Employer    Street             City               State                 Zip Code                            County


Name & Title of Immediate Supervisor:


Your Business Phone: Area Code/Telephone Number          Extension                         Fax #      Area Code/Telephone Number


Your Job Title:                                                      Dates of Employment (Month/Day/Year):
                                                                        From:                         To:

                                                                                Is this a full-time paid position? _________
                                                                                (2,000 hrs. = 1 year) ________ hrs./wk. paid

2. Where Did You Work Prior To #1 Above
Name of Employer:


Name & Title of Immediate Supervisor:


Mailing Address of Employer    Street             City               State                 Zip Code                            County


Your Job Title:                                                      Dates of Employment (Month/Day/Year):
                                                                        From:                         To:

                                                                                Is this a full-time paid position? _________
                                                                                (2,000 hrs. = 1 year) ________ hrs./wk. paid

3. Where Did You Work Prior To #2 Above?
Name of Employer:


Name & Title of Immediate Supervisor:


Mailing Address of Employer    Street             City               State                 Zip Code                            County


Your Job Title:                                                      Dates of Employment (Month/Day/Year):
                                                                        From:                         To:

                                                                                Is this a full-time paid position? _________
                                                                                (2,000 hrs. = 1 year) ________ hrs./wk. Paid




      Revised July 12 CRPS Application                                                                                                       10
TRAININGS/EDUCATIONAL HOURS

Following are the guidelines for educational hour requirements:

                                    100 total hours
                                    6 contact hours of live ethics (not online or home study)
                                    50 contact hours of Alcohol, Tobacco & Other Drug prevention training
                                    20 hours in last 12 months prior to applying



In the space below, chronologically list all applicable trainings, workshops, summer institutes,
college coursework, etc. beginning with the most recent training.

                                                                                          Number of
     Date          Title                                                                Contact Hours




PLEASE BE SURE TO SUBMIT CERTIFICATES OF ATTENDANCE AND LETTERS OF COMPLETION FOR EACH
TRAINING AS LISTED ABOVE. SUPERVISOR OR TRAINING COORDINATOR IN YOUR AGENCY MUST SIGN
INSERVICE HOURS.




    Revised July 12 CRPS Application                                                                         11
                      Additional Space for Chronologically Listing Trainings
                                                                                 Number of
Date        Title                                                              Contact Hours__
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   Revised July 12 CRPS Application                                                         12
           MISSOURI SUBSTANCE ABUSE PROFESSIONAL CREDENTIALING BOARD
              Prevention Code of Ethical Practice and Professional Conduct

Introduction

        This document is the foundation for standards, which will enable the credentialed prevention
professional to measure the propriety of his or her conduct in dealing with clients, other professionals
and other members of the community. All prevention professionals credentialed by MSAPCB are
expected to thoroughly familiarize themselves with the Prevention Code of Ethical Practice and
Professional Conduct. The Board is committed to investigate and sanction those who fail to abide by
its standards.

Principles:

Principle 1: Non-Discrimination

Principle 2: Competence

Principle 3: Integrity

Principle 4: Nature of Services

Principle 5: Confidentiality

Principle 6: Ethical Obligations for Community and Society

Principle 1: Non-Discrimination

Prevention professionals shall not discriminate against service recipients or colleagues based on
race, ethnicity, religion, national origin, sex, age, sexual orientation, education level, economic or
medical condition, or physical or mental ability. Prevention professionals should broaden their
understanding and acceptance of cultural and individual differences and, in so doing, render services
and provide information sensitive to those differences.

Principle 2: Competence

Prevention professionals shall master their prevention specialty’s body of knowledge and skill
competencies, strive continually to improve personal proficiency and quality of service delivery, and
discharge professional responsibility to the best of their ability. Competence includes a synthesis of
education and experience combined with an understanding of the cultures within which prevention
application occurs. The maintenance of competence requires continual learning and professional
improvement throughout one’s career.
   A. Prevention professionals should be diligent in discharging responsibilities. Diligence imposes
       the responsibility to render services carefully and promptly, to be thorough, and to observe
       applicable standards.
   B. Due care requires prevention professionals to plan and supervise adequately, and to evaluate
       any professional activity for which they are responsible.
   C. Prevention professionals should recognize limitations and boundaries of their own
       competence and not use techniques or offer services outside those boundaries. Prevention
    Revised July 12 CRPS Application                                                                 13
      professionals are responsible for assessing the adequacy of their own competence for the
      responsibility to be assumed.
   D. Prevention professionals should be supervised by competent senior prevention professionals.
      When this is not possible, prevention professionals should seek peer supervision or mentoring
      from other competent prevention professionals.
   E. When prevention professionals have knowledge of unethical conduct or practice on the part of
      another prevention professional, they have an ethical responsibility to report the conduct or
      practice to funding, regulatory or other appropriate bodies.
   F. Prevention professionals should recognize the effect of impairment on professional
      performance and should be willing to seek appropriate treatment.

Principle 3: Integrity

To maintain and broaden public confidence, prevention professionals should perform all
responsibilities with the highest sense of integrity. Personal gain and advantage should not
subordinate service and the public trust. Integrity can accommodate the inadvertent error and the
honest difference of opinion. It cannot accommodate deceit or subordination of principle.
   A. All information should be presented fairly and accurately. Prevention professionals should
      document and assign credit to all contributing sources used in published material or public
      statements.
   B. Prevention professionals should not misrepresent either directly or by implication professional
      qualifications or affiliations.
   C. Where there is evidence of impairment in a colleague or a service recipient, prevention
      professionals should be supportive of assistance or treatment.
   D. Prevention professionals should not be associated directly or indirectly with any service,
      product, individual, or organization in a way that is misleading.

Principle 4: Nature of Services

Practices shall do no harm to service recipients. Services provided by prevention professionals shall
be respectful and non-exploitive.
   A. Services should be provided in a way that preserves and supports the strengths and protective
       factors inherent in each culture and individual.
   B. Prevention professionals should use formal and informal structures to receive and incorporate
       input from service recipients in the development, implementation and evaluation of prevention
       services.
   C. Where there is suspicion of abuse of children or vulnerable adults, prevention professionals
       shall report the evidence to the appropriate agency.




Principle 5: Confidentiality

Confidential information acquired during service delivery shall be safeguarded from disclosure,
including but not limited to verbal disclosure, unsecured maintenance of records or recording of an
activity or presentation without appropriate releases. Prevention professionals are responsible for
knowing and adhering to the State and Federal confidentiality regulations relevant to their prevention
specialty.


    Revised July 12 CRPS Application                                                               14
Principle 6: Ethical Obligations for Community and Society

According to their consciences, prevention professionals should be proactive on public policy and
legislative issues. The public welfare and the individual’s right to services and personal wellness
should guide the efforts of prevention professionals to educate the general public and policy makers.
Prevention professionals should adopt a personal and professional stance that promotes health.



Acknowledgments
      The Missouri Substance Abuse Professional Credentialing Board would like to thank the
Prevention Think Tank for their contribution to the preparation of this code.




    Revised July 12 CRPS Application                                                              15
Applicant’s Agreement to the Prevention Code of Ethical Practice and
Professional Conduct

I have read the Prevention Code of Ethical Practice and Professional Conduct and
agree to abide by this code:



Printed Name                                                         Date

Signature                                                            Date


                              AUTHORIZATION AND RELEASE
   I hereby certify all of the information given herein is true and complete to the best of my knowledge
and belief. I also authorize any relevant investigations, or the release of personal information to the
Missouri Substance Abuse Professional Credentialing Board, its agents, or contractors pursuant to
this application/renewal procedure.            I understand falsification of any portion of this
application/renewal will result in my being denied credentialing, or revocation of same upon
discovery.
   I further agree to hold the Missouri Substance Abuse Professional Credentialing Board and its
Board Members, officers, agents, staff, peer evaluators and examiners, free from any civil liability for
damages or complaints by reason of any action that is within the scope and arise out of the
performance of their duties which they, or any of them, may take in connection with this
application/renewal, any examination, the grades with respect to any examination, and/or the failure
of the MSAPCB to issue me said credential or renewal.
   This Authorization and Release shall also apply to personal information requested by the Board at
any time following credentialing in connection with any investigation concerning allegations that could
lead to disciplinary action against me.




Printed Name                                                         Date

Signature                                                            Date




    Revised July 12 CRPS Application                                                                 16
       Missouri Substance Abuse Professional Credentialing Board
(573) 751-9211                                                                                P.O. Box 1250
                                                                             Jefferson City, MO 65102-1250

      PREVENTION PROFESSIONAL EMPLOYMENT VERIFICATION
An applicant is applying to the Missouri Substance Abuse Professional Credentialing Board for certification as a
Certified Reciprocal Prevention Specialist. Please mail this completed form within one week of receipt directly
to the Board at the address listed above. Please give a copy of this form to the applicant for their records and
future reference. Please include a job description for the position held by the employee. Please feel free to
add any additional comments on the back or separate sheet, as this information will be confidential.
Employee's Name: _____________________________________________________________________________
Supervisor's Name (Print):________________________________________________________________________
Agency: ______________________________________________________________________________________
Address: _____________________________________________________________________________________
_____________________________________________________________________________________________
Telephone: ___________________________________________________________________________________
Today’s Date: _________________________________________________________________________________
Applicant’s Job Title:____________________________________________________________________________
Please make copies of this sheet and use one sheet for each job title                   Attach a Job Description
Start Date: ______________________________                      End Date: _____________________________
Only experience within last 10 years is applicable              Use current date if still in position

For each of the following 5 Performance Domains, please list the total number of hours of work experience the
applicant obtained while working in this position.

Planning and Evaluation:                                     _________________________
Education and Skill Development:                             _________________________
Community Organization:                                      _________________________
Public Policy and Environmental Change:                      _________________________
Professional Growth and Responsibility:                      _________________________

Total hours in all domains:                                  _________________________
Maximum total number of hours allowed by the MSAPCB is 166.67 hours per month or 2,000 hours in 12 months


Superior's Signature: ______________________________________ Title: _______________________________
Signed and sworn to before me this ________ day of _______________________, ________________________
Notary Public: _________________________________________________________________________________
My Commission expires: ____________________________, _________________________________________

                                                                           (NOTARY SEAL)
This form must be mailed to the MSAPCB
with a job description attached


     Revised July 12 CRPS Application                                                                           17
              SUPERVISED PRACTICUM OF THE 5 PERFORMANCE DOMAINS
INSTRUCTIONS: On this form, document only the number of hours the applicant has already
completed performing each domain. A minimum of 300 total hours must be documented with a
minimum of 10 hours in each performance domain.

  This document must be signed by either a CRPS or a MACSAPP who has attended the ACT Missouri
                             sponsored Prevention Supervision Course.
 Planning and Evaluation – Assessing            Performed   Public Policy and Environmental Change –                    Performed
 community needs. Developing a prevention         Hours     Identifying/informing policy makers. Planning public          Hours
 plan. Selecting strategies to meet the needs               policy initiatives. Gaining support of decision makers.
 of target populations. Applying sound                      Establishing a relationship with the media/being a
 prevention theory and practice. Identifying                credible resource. Promoting advocacy for prevention.
 funding sources. Reviewing evaluation
 options. Conducting evaluation activities.
 Documenting project activities and outcomes.
 Refining the prevention program.
 Education and Skill Development –              Performed   Professional Growth and Responsibility –                    Performed
 Tailoring education and skill development.       Hours     Attaining knowledge of current prevention theory and          Hours
 Connecting prevention theory and practice                  practice. Networking with colleagues/others in the field.
 using current research and program models.                 Adhering to legal and professional standards.
 Maintaining fidelity when replicating                      Recognizing community norms to ensure sensitivity to
 research based prevention programs.                        unique needs. Developing cultural competence.
 Developing culturally competent education
 and training. Conducting education and skill
 development activities. Educating consumers
 by providing accurate and appropriate
 materials. Providing prevention information
 to professionals.
 Community Organization – Defining the          Performed
 community through demographics and core          Hours
 values. Identifying key community members.
 Identifying/engaging community leaders.
 Identify needs and resources. Developing a
 prevention plan through collaboration with
 members of the community. Supporting the
 community through technical assistance.
 Developing the capacity of the community.


Applicant's Name: _________________________________________________________
Name of Supervisor: ___________________________________                    Credential #:_____________________________________
Agency: _________________________________________________________________________________________________

Title: ___________________________________________________________________________________________________
Address:_________________________________________________________________________________________________

Beginning and ending dates the hours documented above were supervised: _____________________________________________

Supervisor’s Printed Name: __________________________________________________________________________________
Supervisor's Signature: ______________________________________________                     Date:_________________________________


Total Performed Hours Documented Above: ________________________ _____________________________________________


 PLEASE MAIL THIS ORIGINAL FORM DIRECTLY TO THE BOARD OFFICE, MSAPCB, P.O. BOX 1250,
      JEFFERSON CITY, MISSOURI 65102-1250 AND PROVIDE A COPY TO THE APPLICANT.


    Revised July 12 CRPS Application                                                                                                18
           MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
           FAMILY CARE SAFETY REGISTRY
           WORKER REGISTRATION
  PLEASE TYPE OR PRINT CLEARLY
SECTION A: WORKER TYPE (CHECK ONE BOX ONLY)
     CHILD CARE WORKER ($9.00)           PERSONAL CARE WORKER ($9.00)        xx VOLUNTARY REGISTRANT
     ELDER CARE WORKER ($9.00)           RECIPIENT OF STATE OR FEDERAL FUNDS ($9.00)  FOSTER PARENT (NO FEE)
SECTION B: IDENTIFYING DATA FOR BACKGROUND SCREENING
LAST NAME                                            FIRST NAME                           MIDDLE NAME


MAIDEN AND PRIOR NAMES USED


SOCIAL SECURITY NUMBER (ATTACH COPY OF SOCIAL                         DATE OF BIRTH                    GENDER                 TELEPHONE NO.
SECURITY CARD)                                                                                               MALE             (OPTIONAL)

                 -               -                                          /         /                     FEMALE            (       )
MAILING ADDRESS
STREET ADDRESS OR POST OFFICE BOX                               CITY                          STATE        ZIP CODE           COUNTY


HOME ADDRESS (if different than mailing address)
STREET ADDRESS                                                  CITY                          STATE        ZIP CODE           COUNTY


SECTION C: CURRENT EMPLOYER INFORMATION (IF APPLICABLE)
EMPLOYER NAME                                                            CONTACT PERSON                                       PHONE NUMBER
                                                                                                                              (       )
ADDRESS                                                                  CITY                                      STATE      ZIP CODE


SECTION D: AUTHORIZATION TO RELEASE BACKGROUND SCREENING INFORMATION
The information provided is complete and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify information required
on this form. I grant my permission for the Missouri Department of Health and Senior Services (DHSS) to obtain any and all background information
authorized by law to process this request. Futhermore, I authorize the Missouri Department of Health and Senior Services to release the fact that I am
a registrant in the Family Care Safety Registry (FCSR) and any related background information to the requestor of the FCSR for employment purposes
only, as provided in 210.921, subsection 1 subdivision (1) and (2), RSMo. For purposes of the FCSR, “employment purposes” includes direct
employer/employee relationships, prospective employer/employee relationships, and screening and interviewing of persons or facilities by those
persons contemplating the placement of an individual in a child care, elder care or personal care setting. I understand that if I dispute the information
contained in the FCSR I have the right to appeal the accuracy in the transfer of information to the FCSR within thirty (30) days of receiving the results
of the background screening determination.

NOTICE: The FCSR may choose to deposit the check enclosed electronically as an ACH debit entry to your designated bank account. I understand
that my signature below authorized my Financial Institution to deduct this payment from my account. In the event that DHSS or its subcontractor, is
unable to secure funds from your account or you provide insufficient or inaccurate information regarding your account, your obligation to the DHSS will
remain unpaid and further collection action may be taken by the DHSS or its subcontractor, including, but not limited to, returned check fees.
SIGNATURE OF APPLICANT (REQUIRED IN INK)                                                      DATE
                                                                                                               /                  /
   IMPORTANT
          Individuals are required to register one time only.
          Contact 1-866-422-6872 (toll-free) if you have questions on how to complete this form
          Read back of form for instructions and information on registrant notification and appeal rights
        
                         Send this form in with your application and a
           Send completed registration form, copy of Social Security card and required fee to:
                      Missouri Department of Health and Senior Services
                      Attn: Fee Receipts
                         copy of your social security card.
                      P.O. Box 570
                      Jefferson City, MO 65102
   MO 580-2421 (FP)




     Revised July 12 CRPS Application                                                                                                                19
                     DOCUMENTATION OF DISABILITY RELATED NEEDS
If you have a learning disability, psychological disability, physical disability, or other hidden disability which requires an
accommodation in taking the IC&RC International Prevention Specialist Examination, please: 1) have this section completed by an
appropriate professional (education professional, doctor, psychologist, psychiatrist) to certify your disability/condition requires the
requested test accommodation, and 2) complete the Test Applicant Information section below. If accommodation is not requested
in advance, we cannot guarantee the availability or accommodation on-site.

IF YOU HAVE EXISTING DOCUMENTATION OF HAVING THE SAME OR SIMILAR ACCOMMODATION PROVIDED
TO YOU IN ANOTHER TEST SITUATION, YOU MAY SUBMIT SUCH DOCUMENTATION INSTEAD OF HAVING THIS
PORTION OF THE FORM COMPLETED.

I have known _______________________________________ since ____________________________ in my capacity
                            (name of test applicant)                                  (date)
as a ____________________________________________. Today's date: ___________________________________
                    (professional title)
Signature: _________________________________________                License # (if applicable): _____________________

Nature of applicant’s disability: _____________________________________________________________________
_______________________________________________________________________________________________

The applicant has discussed with me the nature of the test to be administered. It is my opinion that because of this applicant's
disability, he/she should be accommodated by providing the following:

______ Accessible Test Site
______ Braille       ______ Large Print       ______ Tape
______ Reader as accommodation for visual impairment
______ Scribe/amanuensis as accommodation for visual or motor impairment
______ Reader as accommodation for learning disability
______ Scribe/amanuensis as accommodation for learning disability
______ Sign Language Interpreter
______ Extended testing time
______ Separate testing area
______ Use of computer or other adaptive equipment (specify): ____________________________________________
______ Other (specify): ___________________________________________________________________________
                         ___________________________________________________________________________
                         ___________________________________________________________________________

*************************************************************** *

                                            TEST APPLICANT INFORMATION SECTION

Applicant's Signature:                                               Soc. Sec. #:

Address:                                                             Work Phone #:

                                                                     Home Phone #:


                         Mail to: Missouri Substance Abuse Professional Credentialing Board
                                   P.O. Box 1250, Jefferson City, MO 65102-1250




  Revised July 12 CRPS Application                                                                                                 20

								
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