Fillable Criteria for Certified Reciprocal Prevention Specialist (CRPS) (Missouri Credentialing Board)

Fill Online, Printable, Fillable, Blank Criteria for Certified Reciprocal Prevention Specialist (CRPS) (Missouri Credentialing Board) Form

Use Fill to complete blank online MISSOURI CREDENTIALING BOARD pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Criteria for Certified Reciprocal Prevention Specialist (CRPS) (Missouri Credentialing Board)

On average this form takes 34 minutes to complete

The Criteria for Certified Reciprocal Prevention Specialist (CRPS) (Missouri Credentialing Board) form is 21 pages long and contains:

  • 0 signatures
  • 32 check-boxes
  • 123 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Missouri Credentialing Board forms online.

BROWSE MISSOURI CREDENTIALING BOARD FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
Revised August 2019 CRPS Application
Missouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
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/HSE & 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.
• 120 Performing Hou
rs of Supervised Practicum in the IC&RC prevention
domains with a minimum of 10 performing hours in each domain
• 120
Total Contact Hours of Education relating to the IC&RC prevention
domains. Within the 12
0 hours, there are some specific requirements
including:
6 contact hours of live prevention ethics (not online or home study)
24 contact hours of Alcohol, Tobacco, and Other Drug specific
training
20 hours of the 120 hours must have been obtained in the 12
months prior to applying
• Pass the IC&RC International Prevention Specialist Examination
2
Revised August 2019 CRPS Application
CHECK LIST FOR CRPS APPLICATION
1. You have completely filled out the application.
2. You have signed the Prevention 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. If your agency has conducted a FCSR background check on you within the last 30
days, you may submit the results to help expedite the application process.
4. You have submitted the $335.00 with this application or have provided your credit card information on
page 7 of this application. Applications will not be reviewed until payment is received.
5. The appropriate person has completed and signed the Prevention Professional Employment Verification
Form and you have included the completed form with the application.
6. The appropriate High School/HSE or college transcripts were included.
7. The appropriate certificates of completion are attached documenting the total hours of education needed
for the CRPS.
8. The supervised practicum form has been included by a MCB Qualified Prevention Supervisor. The form
documents at least 120 total hours of practicum hours with at least a minimum of 10 hours in each of the
performance domains.
9. If applicant does not hold the Missouri Prevention Specialist (MPS) 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)
10. Typically, applications are reviewed within two weeks of receipt in the MCB office. If you have not
received written correspondence from the MCB 3 weeks after mailing your application to the MCB, call
the MCB.
11. If you took and passed the examination and you have not received correspondence from the MCB, check
the Professional Search on the MCB web site homepage at www.missouricb.com. Type in your last
name. If your application is complete, your credential information will be displayed and you should
have received your welcome letter and certificates by e-mail.
3
Revised August 2019 CRPS Application
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 MCB, 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 prevention performance domains.
All education/training taking place outside the applicant's place of employment must be documented through
proof of attendance including transcripts 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 prevention related
positions with job duties that are specific to the prevention performance domains. 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.
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 PERFORMANCE DOMAINS is defined as providing the
performance domains while under supervision.
The supervision of the experience of providing the 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
performance domains. Applicants must complete a minimum of 10 hours performing each of the performance
domains with a total supervised practicum of 120 hours.
The practicum hours must be signed by a MCB Qualified Prevention Supervisor.
D. PERFORMANCE DOMAINS DEFINITIONS: Refer to the PS Candidate Guide on the MCB web
site at www.missouricb.com under the Education Box/Candidate Guide link.
4
Revised August 2019 CRPS Application
Missouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
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 MCB office.
2. The application must be typed or neatly printed.
3. If you do not already hold the Missouri Prevention Specialist 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. You may pay by check, money order, or by providing credit card
information on page 7 of the application packet. Applications will not be reviewed until payment is
received.
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 MCB office staff for instructions on how to appeal the
denial of your application.
9. All materials submitted to the MCB office become property of the MCB.
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 MCB 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 or e-mail your application.
Revised August 2019 CRPS Application
5
Missouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
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 information on how to obtain a free Candidate Guide from our web site as well as a free
study guide. In addition, you will receive information regarding IC&RC practice exams that can be
purchased.
3. The CRPS credential is a reciprocal credential with other IC&RC member boards that offer the
prevention credential. You can contact the MCB office for more information on reciprocity.
Revised August 2019 CRPS Application
6
Important Notice To Applicants
According to Missouri Credentialing Board (MCB) Policies and Procedures, the following rules apply to those
seeking a MCB credential.
1. No individual currently under any type of court supervision can apply for a MCB 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 MCB:
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. Any crime against a minor
D. A person who has been convicted of, found guilty to, plead guilty to or nolo contendere to any of
the Disqualifying Crime (s) Pursuant to Section 630.170, RSMo. The crime (s) will only disqualify
an applicant if the crime (s) were a felony. Please view information about Section 630.170, RSMo
on the MCB web site www.missouricb.com under the Disqualifying Crimes Link.
3. If an individual has applied for and been given an exception from the Department of Mental Health, the
individual may apply for a MCB credential. Please send in proof of exception with your application.
Revised August 2019 CRPS Application
7
APPLICATION
FOR
Certified Reciprocal Prevention Specialist (CRPS)
Appropriate fee must be submitted with application.
MISSOURI CREDENTIALING BOARD
428 E. Capitol, 2
nd
Floor
JEFFERSON CITY, MISSOURI 65101
TELEPHONE: (573) 616-2300
WEB SITE: www.missouricb.com
EMAIL: help@missouricb.com
Please Mark Credit Card Type:
1. Visa _____________
2. MC _____________
3. Discover _____________
CC Expiration Date: _____/_______
Credit Card #: __________-______________-______________-____________
Credit Card 3 Digit Verification Code: ________________________________
Revised August 2019 CRPS Application
8
THIS APPLICATION MUST BE TYPED OR PRINTED NEATLY
All Applications Become the Property of MCB
Please check if you are: ______ New Applicant ______ Upgrade Applicant
Applicant’s Name: ___________________________________________________________________________
First Middle Last Name Suffix (Jr., II)
___________________________________________________________________________________________________________
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.missouricb.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 in Section 630.170 RSMo (view
www.missouricb.com; Disqualifying Crimes link), you may not apply for this credential without an exception from the
Department of Mental Health.
Have you ever knowingly been contacted by a Children’s Division employee regarding a CHILD ABUSE and/or
CHILD NEGLECT incident involving you? ______Yes ______No
If yes, please go to the www.missouricb.com
website, print off the “Child Abuse/Neglect Statement”, fill out the form
and submit with your application. In addition, please contact the Children’s Division at 573-751-4920 and request a
report of the incident to include with this application.
Revised August 2019 CRPS Application
9
Education/Degree Information
Please mark your highest level of education completed:
1. High School Diploma/HSE: _____
2. Addiction Certificate Program: _____
3. Associate Degree: _____ Degree Program: ________________________
4. Bachelor Degree: _____ Degree Program: ________________________
5. Master Degree/Higher: _____ Degree Program: ________________________
An applicant may document High School Diploma or HSE or College/University degree by:
1. Submitting copy of High School Diploma/HSE
2. Submitting official or unofficial College/University transcripts. Please ensure the transcript shows the
applicable degree being conferred.
Where Does the Applicant Currently Work?
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
TRAININGS/EDUCATIONAL HOURS
Following are the guidelines for educational hour requirements:
120 total hours
6 contact hours of live prevention ethics (not online or home study)
24 contact hours of Alcohol, Tobacco & Other Drug specific training
20 hours in last 12 months prior to applying
Revised August 2019 CRPS Application
10
Applicant’s Agreement to the Prevention Code of Ethical Practice and Professional
Conduct
I have read the Current Prevention Code of Ethical Practice and Professional Conduct as listed
on the MCB web site www.missouricb.com
, MCB Ethics Code Link 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
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 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 MCB 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 August 2019 CRPS Application
11
Missouri Credentialing Board
428 E. Capitol, 2
nd
Floor, Jefferson City, MO 65101
PREVENTION PROFESSIONAL EMPLOYMENT VERIFICATION
An applicant is applying to the Missouri Credentialing Board for certification as a Certified Reciprocal
Prevention Specialist. Please complete this form and provide a copy to the applicant to include with their
application.
Applicant's Name: _____________________________________________________________________________
Supervisor's Name (Print):________________________________________________________________________
Agency: ______________________________________________________________________________________
Address: _____________________________________________________________________________________
_____________________________________________________________________________________________
Telephone: ___________________________________________________________________________________
Email: _______________________________________________________________________________________
Today’s Date: _________________________________________________________________________________
Within the last 10 years from the date listed above, please list the composite total number of hours the
applicant spent working with substance use disorder clients in the following domains: (Please list all hours
worked as this form replaces any previous employment forms submitted with prior applications)
The formula for computing hours is to take the total number of months worked within the last 10 years and
multiply that by 167 hours per month to get the total number of hours. Then divide that total number as
appropriate into the 6 domains below.
Planning and Evaluation: _________________________
Prevention Education & Service Delivery _________________________
Communication: _________________________
Community Organization: _________________________
Public Policy and Environmental Change: _________________________
Professional Growth and Responsibility: _________________________
Supervisor's Name (Printed): ___________________________________________________________________
Supervisor’s Signature: ________________________________________________________________________
Date: ______________________________________________________________________________________
Revised August 2019 CRPS Application
12
SUPERVISED PRACTICUM OF THE PERFORMANCE DOMAINS
INSTRUCTIONS: On this form, document only the number of hours the applicant has already
completed performing each domain. A minimum of 120 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 MAPS who has attended the ACT Missouri
sponsored Prevention Supervision Course.
Applicant's Name(Print):___________________________________________________________
MCB Qualified Supervisor (Print):_____________________________________________________________________________
Agency:__________________________________________________________ Prevention
Supervision Number:_______________
Total # Supervised Work Hours (Must be a minimum of 120 hours):__________________________________________________
Please indicate on the domain lines below how many of the Total # Supervised Work Hours listed above were in each domain. The
total listed on the line above should equal the sum total of the 6 domains (Must be a minimum of 10 hours listed for each domain):
Planning and Evaluation: _________________________ Hours
Prevention Education & Service Delivery _________________________ Hours
Communication: _________________________ Hours
Community Organization: _________________________ Hours
Public Policy and Environmental Change: _________________________ Hours
Professional Growth and Responsibility: _________________________ Hours
MCB Qualified Supervisor’s Signature:____________________________________________
Today’s Date: _____________
Please complete this form and provide a copy to the applicant to include with their application.
Revised August 2019 CRPS Application
13
DOCUMENTATION OF DISABILITY-RELATED NEEDS
Please have this section completed by an appropriate professional (physician, psychologist, psychiatrist) to ensure that
your board is able to provide the required exam accommodations. Submitted documentation must follow ADA guidelines
in that psychological or psychiatric evaluations must have been conducted within the last three years. All
medical/physical conditions require documentation of the treating physician’s examination conducted within the previous
three months.
Professional Documentation:
I have known ___________________________________________ since _____/_____/_____ in my
Exam Candidate Date
capacity as a ______________________________________________.
Professional Title
The candidate discussed with me the nature of the exam to be administered. It is my professional opinion that,
because of this candidate’s disability described below, he/she should be accommodated by providing the special
arrangements listed below:
Description of Disability:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Signed: ______________________________________________________ Title: ___________________________
Printed Name: _________________________________________________________________________________
Address: ______________________________________________________________________________________
City/State/Zip: _________________________________________________________________________________
Telephone Number: _____________________________ Email:__________________________________________
License Number: _______________________________ Date: ___________________________________________
(if applicable)
Revised August 2019 CRPS Application
14
REQUEST FOR SPECIAL ACCOMMODATIONS
If you have a disability that requires special testing accommodations, please complete this form and the Documentation
of Disability-Related Needs and return it to your IC&RC member board for processing. The information you provide and
any documentation regarding your disability and your need for accommodations in testing will be treated with strict
confidentiality. Submitted documentation must follow ADA guidelines in that psychological or psychiatric evaluations
must have been conducted within the last three years. All medical/physical conditions require documentation of the
treating physician’s examination conducted within the previous three months.
Preferred Exam Date: ________________ Preferred Exam Location: __________________________________________
Name: ____________________________________________________________________________________________
Home Address:_____________________________________________________________________________________
City/State/Zip: _____________________________________________________________________________________
Daytime Telephone Number: _________________________________________________________________________
Email: ____________________________________________________________________________________________
Special Accommodations:
I request special accommodations for the following IC&RC ADC examination
Please provide (check all that apply):
________ Special seating or other physical accommodations
________ Reader
________ Large print exam
________ Extended testing time (time and a half)
________ Distraction-free room
________ Other special accommodations (please specify)
Comments:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Print Name: _______________________________________________________________________________________
Signature: _________________________________________________________________________________________
Date:_____________________________________________________________________________________________
Revised August 2019 CRPS Application 15 15
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 SECURITY
CARD)
- -
DATE OF BIRTH
/ /
GENDER
MALE
FEMALE
TELEPHONE NO.
(OPTIONAL)
( )
MAILING ADDRESS
STREET ADDRESS OR POST OFFICE BOX
STATE
ZIP CODE
COUNTY
HOME ADDRESS (if different than mailing address)
STREET ADDRESS
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 completed registration form, copy of Social Security card and required fee to:
Missouri Department of Health and Senior Services
Attn: Fee Receipts
P.O. Box 570
Jefferson City, MO 65102
MO 580-2421 (FP)
Submit this form with your application and a copy of your SS card. If your
agency has ran a FCSR check within the last 30 days, you can submit the
results with this form which may speed up the application
process. By
doing so, you give permission for your agency to share their FCSR results.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Criteria for Certified Reciprocal Prevention Specialist (CRPS) (Missouri Credentialing Board)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 28 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document