Certification Exam Application
2009 PSR/RPS CANADA CONFERENCE EXAM
Before completing this application please read the Certification Application Instructions. If you did not receive a copy of the Instructions with this application, please visit the USPRA Website at www.uspra.org. Incomplete applications may be delayed or denied.
Section 1: Personal Information: HOME MAILING ADDRESS
Last Name: Maiden/Former Last Name: Date of Birth: Address: City: Phone (Home): Fax (Home): E-mail: Can you be contacted at work? Yes No State/Prov: Zip: Phone (Work): Fax (Work): Country: Social Security or Gov’t Issued Identification No.: First Name: Middle:
Test Administration
E-mail (Work):
September 25, 2009 (Application Deadline: June 15, 2009) Thunder Bay, Ontario 1:30 p.m. – 4:30 p.m. Applications postmarked after the late deadline will be evaluated for the October 22-23 Exam. NO EXCEPTIONS.
OFFICE USE ONLY Transcript Employment Verification Continuing Education & Training Background Check Payment
Psychiatric Rehabilitation Certification Program Application – Revised January 2009 Application fees are subject to change without notice.
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Applicant’s Full Name:
Education & Academic Preparation
An original transcript documenting your highest completed degree must be included with your application*. DO NOT SEND TRANSCRIPTS OF PARTIALLY COMPLETED DEGREES. High School/GED College/School: Field of Study: Voc/Trade AA BA/BS MA/MS Doctorate/Professional Year Graduated: Is this Degree/Certificate in Psychiatric Rehabilitation? Yes No
I have included: An unofficial or copy of my transcript An official transcript in a sealed envelope as provided by my educational institution An official transcript will be mailed to USPRA by my educational institution Address: City: State/Prov: Zip: Country:
* Be sure to allow time for your educational institution time to process your request for transcript.
Work Experience
List employment in psychiatric rehabilitation in order, starting with the present or most recent employer. This employment must be providing services to adults with serious mental illness. If the work was part time, it will be converted to full time equivalents to meet the eligibility criteria. The total years of employment must meet the minimum eligibility criteria (see page 2 of the Application Manual). Indicate if this position is primarily direct-service or primarily supervisory. For the purposes of the application, supervisor level means supervisor, administrator, trainer, consultant, researcher, advocate or any position that is not primarily direct-service. Additional Employment Information must be added on additional sheets of paper using the same format as provided below. Make copies as needed. I am (check one): Currently Employed in PSR Job Title: Employed/Not PSR Currently not employed This position is: Paid Unpaid
This position is primarily: Executive/Management Supervisory Direct Service Academic Date Started: Agency Name: Agency Address: City: Supervisor’s Name & Title: Major Duties (job description may be attached): State/Prov: Zip: Country: Date Left: # Hours/Week Worked: Agency Phone:
Please Make Additional Copies if Needed
Psychiatric Rehabilitation Certification Program Application – Revised January 2009 Application fees are subject to change without notice.
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Applicant’s Full Name:
Employment Verification
Applicant: Please complete the top portion of the form only. Next, have your employer do the following: complete the verification form, place it in a sealed envelope, and place his or her signature across the back flap. Afterwards, they should give you the sealed, signed envelope to include with your application packet. Please review page 3 of the Application Manual for detailed directions on completing this section of your application. Make copies of this form as needed. The Certification Commission reserves the right to contact your employer(s) for further confirmation if required. TO BE COMPLETED BY THE APPLICANT: I AUTHORIZE INVESTIGATION OF EMPLOYERS LISTED ON MY APPLICATION TO GIVE USPRA ANY AND ALL INFORMATION CONCERNING MY CURRENT AND PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND HEREBY RELEASE THE COMPANY FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION.
Signature of Applicant
Date
USPRA ID
(office use only)
Verification: (Applicant: Please PRINT your information below.) Employee Name (Applicant): Position Title: This position is primarily: Start Date: Employer: Employer Address: City: Employer Contact: State/Prov: Zip: Phone: Country: Supervisory End Date: Direct Service Paid Hrs/week: Unpaid
TO BE COMPLETED BY THE EMPLOYER: The above individual is applying for a Certified Psychiatric Rehabilitation Practitioner designation. We are at this time verifying his/her employment and that the employment is/was in the field of psychiatric rehabilitation. Please check the appropriate statement, place form in a sealed envelope, sign the envelope across the back flap and return to the applicant as soon as possible. Questions: 410-789-7054 YES, the above employment information is accurate, and this position is related to providing psychiatric rehabilitation for adults with serious mental illness. The employee’s work had a job description; was regularly scheduled; was supervised by a psychiatric rehabilitation practitioner (someone familiar with psychiatric rehabilitation but not necessarily certified) and was regularly evaluated. NO, the above employment information is inaccurate or this position is not related to providing psychiatric rehabilitation for adults with serious mental illness. The correct information is attached. _____________ _____________________ Date
_________________________________________________ Signature/Title
Please enclose form in a sealed envelope, sign across the back flap and return to the applicant ASAP.
Psychiatric Rehabilitation Certification Program Application – Revised January 2009 Application fees are subject to change without notice.
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Applicant’s Full Name:
Training in Psychiatric Rehabilitation
If you have selected an eligibility criterion that does not require training, you may skip this section. Otherwise, please document 45 in-class hours of training. Training experience will be verified. Make copies of the form as needed. Training Topic: Presenter(s): Sponsoring Organization: Place: Training Topic: Presenter(s): Sponsoring Organization: Place: Training Topic: Presenter(s): Sponsoring Organization: Place: Training Topic: Presenter(s): Sponsoring Organization: Place: Training Topic: Presenter(s): Sponsoring Organization: Place: Phone: Date: Subtotal Training Hours (this page only): Total Training Hours (all pages): Applicant’s Full Name: Phone: Date: Total Contact Hours: Phone: Date: Total Contact Hours: Phone: Date: Total Contact Hours: Phone: Date: Total Contact Hours: Total Contact Hours:
Psychiatric Rehabilitation Certification Program Application – Revised January 2009 Application fees are subject to change without notice.
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Licensing
Have you been denied a professional license or certification? Have you been the subject of any sanctions, including revocation, by a licensing or credentialing organization? Are there any pending complaints against you regarding your work in mental health? Yes No Yes No Yes No
If you answered yes to any of the above questions, please explain the circumstances below (if you need additional space
attach a separate paper):
Criminal Background Check
All candidates must complete the Background Investigation Authorization Form included in this application. If you do not submit a complete and signed form, your application will NOT be processed. In addition, please answer the following questions: Have you ever been convicted of a felony? Have you ever been convicted of any other offense against the law?* (See below before answering) Yes No Yes No
If you answered yes to any of the above questions, please explain the circumstances on a separate sheet of paper.
*You are not required to furnish information for: 1) any offense committed prior to your seventeenth birthday, unless such offense was bound over for trial in Superior Court; 2) a FIRST misdemeanor conviction for drunkenness, simple assault, speeding, minor traffic violations, or disturbance of the peace; 3) a misdemeanor conviction which occurred more than five years ago, unless you have been convicted of any offense within the last five years; or 4) a misdemeanor conviction which resulted in a period of incarceration that ended more than five years ago unless you have been convicted of any offense within the last five years.
Note: You are not required to report felony arrests that did not result in a conviction, or resulted in a conviction for a nonreportable misdemeanor. However, such information is likely to be included in your Background Check Report and selfdisclosing the full facts may avoid delays in processing your application. All information is kept in strict confidence.
Psychiatric Rehabilitation Certification Program Application – Revised January 2009 Application fees are subject to change without notice.
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AUTHORIZATION AND RELEASE FOR THE PROCUREMENT OF A CONSUMER AND/OR INVESTIGATIVE CONSUMER REPORT
I, the undersigned, do hereby authorize the CPRP Certification Commission, by and through its independent contractor, to procure a criminal background report on me. These above-mentioned reports may include, but are not limited to, my driving history, including any traffic citations; a social security number verification; present and former addresses; criminal and civil history/records; any other public record. I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any investigative consumer report of which I am the subject upon my written request, if such is made within a reasonable time after the date hereof. I also understand that I may receive a written summary of my rights under 15 U.S.C. § 1681et. seq. I further authorize any person, business entity or governmental agency who may have information relevant to the above to disclose the same to the Certification Commission, by and through its independent contractor, including, but not limited to, any and all courts, public agencies, law enforcement agencies and credit bureaus, regardless of whether such person, business entity or governmental agency compiled the information itself or received it from other sources. I hereby release Certification Commission, its independent contractor and any and all persons, business entities and governmental agencies, whether public or private, from any and all liability, claims and/or demands, by me, my heirs or others making such claim or demand on my behalf, for providing a consumer report and/or investigative consumer report hereby authorized. I understand that this Authorization/Release form shall remain in effect for the duration of review of my application for certification. Further, I certify that the information contained on this Authorization/Release form is true and correct and that my application or certified status may be terminated based on any false, omitted or fraudulent information.
SIGNATURE:
DATE:
Printed Name:
First
Middle
Last
Other Names Used/Dates Used: Social Security Number: Current Address: Street /P. O. Box Addresses for the past seven years: Street /P. O. Box Street /P. O. Box City City State State Zip Code Zip Code County County Dates Dates Yes Yes Yes Yes No No No No City State Zip Code County Dates __ Date of Birth (MM/DD/YYYY):
Have you ever been convicted of a felony or misdemeanor in a county, state, or federal court? Have you ever been convicted of a crime in a military court martial? Have you ever been sanctioned or had a professional license suspended or revoked? Are you currently under any investigation or pending charge?
Any questions answered yes should be explained in sufficient detail to allow for a full assessment of the situation. Incomplete or contradictory information may result in delay or denial of your application. This form will be provided to IEI for processing and is NOT a part of your permanent CPRP record. The information provided will enable us to properly identify you in the event we find adverse information during the course of our background investigation.
Psychiatric Rehabilitation Certification Program Application – Revised January 2009 Application fees are subject to change without notice. Page 6
Applicant’s Full Name:
Agreement to Abide by the USPRA Code of Ethics
Each applicant for the Certification Program is required to abide by the Practitioner Code of Ethics. Please read the Code of Ethics carefully, before signing the statement below. A summary of Major Ethical Principals is included in this application; you may download a copy of the complete code of ethics at www.uspra.org. The Certification Commission Ethical Review Committee will review any complaints made about unethical conduct. If a complaint is ruled a violation of ethical conduct, a practitioner’s CPRP credential may be suspended or revoked. I have read the Practitioner Code of Ethics for Psychiatric Rehabilitation Practitioners and I agree to abide by the Code. ____________________________________________ Signature of Applicant _____________________________________ Date
Signature and Verification of Information
I understand that, in order to evaluate my application, the Certification Commission will verify my education and employment, licenses and any criminal violations. I agree to cooperate in such review and allow others to provide information regarding my abilities and education. I hereby solemnly declare and affirm, under the penalties of perjury, that the facts and matters contained in the foregoing application are true and correct.
____________________________________________ Signature of Applicant _____________________________________ Date
Submitting Your Application Packet: Before submitting your application, please confirm that you have:
□ □ □ □ □ □ □ □ Submitted your application before the posted application deadline Included all Applicable Fees including late fees if required Included your signed and sealed Employment Verification Form(s) Included an original copy of your transcript documenting your highest degree Signed your Criminal Background Investigation Authorization Form Signed that you have read and agree to abide by the USPRA Code of Ethics Signed the Verification of Information Included all required application fees
Mail your complete application packet to: USPRA/Certification Program Certification Commission 601 Global Way, Suite 106 Linthicum, MD 21090 Questions? Email: certification@uspra.org Online: http://www.uspra.org/certification Phone: 410-789-7054 Fax: 410-789-7675
Thank You for Applying to Sit for the USPRA Certification Examination!
Psychiatric Rehabilitation Certification Program Application – Revised January 2009 Application fees are subject to change without notice. Page 7
Please allow up to 8 weeks for application processing.
Payment Information Form
This page MUST be placed on top of your application packet, as a cover sheet. Applicant’s Full Name:
BILLING ADDRESS:
Last Name: Agency: Address: City: Phone: E-mail: State/Prov: Zip: Fax: Country: First Name:
Middle:
APPLICATION FEES – All application fees are non-refundable.
Non-Member: $425 RPS/PSR Canada Member: $365 Staff Member of a RPS/PSR Canada Organizational Member: $365 Incomplete Application Fee $50 (This fee will be assessed if the application is incomplete)
TOTAL DUE: $ ______________
Be sure to include all applicable fees.
PAYMENT METHOD: Check (#_____________) Money Order
USPRA Member ID: ________________________ Required for USPRA Members and Staff of USPRA Organizational Members.
American Express VISA MasterCard
Credit Card #:
_______
Expiration Date:
Card Holder’s Name: ________________________________________________________ Signature: ________
PLEASE NOTE: Applications postmarked after the late deadline will be evaluated for the October 2009 Exam.
**NO EXCEPTIONS**
Psychiatric Rehabilitation Certification Program Application – Revised January 2009 Application fees are subject to change without notice.
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