Fillable Date Soc Sec # (Pennsylvania Certification Board)

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Date Soc Sec # (Pennsylvania Certification Board)

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PCB Revised January 2021 1
RECERTIFICATION DIRECTIONS – READ DIRECTIONS CAREFULLY
Prior to submitting your recertification application to PCB, please review the following list to be sure you have included all the
necessary documentation.
Recertification application can be submitted no sooner than three (3) months prior to the credential’s expiration date.
Completed application page - page 6
Completed education and training page - page 7 - Do not send copies of your certificates.
Recertification fee and any other applicable fees – page 8
If there are any problems with the application, you will be notified by email. Keep a photocopy of the entire application
for your records.
To check the status of your recertification application, you can use the Credential Search on the homepage of our
website: www.pacertboard.org
. Simply enter your last name and click “Apply”.
TO SUBMIT YOUR APPLICATION, CHOOSE ONE OF THE FOLLOWING:
• Mail: PCB, 298 S. Progress Avenue, Harrisburg, PA 17109
• Email: info@pacertboard.org NOTE: Only PDFs are acceptable. PCB does not accept photos of applications.
• Fax: 717-540-4458
Please allow 5-10 business days for review and processing of your recertification application.
To confirm receipt of your application, or check on the status, you must email info@pacertboard.org.
RECERTIFICATION INFORMATION FOR ALL CREDENTIALS
1. Recertification record keeping is the responsibility of the certified professional. All recertification documents and
application forms should be submitted together. Keep copies of everything submitted.
2. Education must be acquired no earlier than two years prior to the applicant’s current expiration date.
3. Recertification is considered late if you are mailing it and it is postmarked after your expiration date. Recertification is
considered late if you are submitting it electronically and it is after your expiration date. If recertification is not
completed prior to the expiration date, it is considered lapsed.
4. Education is defined as formal, structured instruction in the form of workshops, seminars, institutes, in-services, and
college/university credit courses and distance learning/online courses.
RECERTIFICATION APPLICATION
For All Credentials
PCB Revised January 2021 2
AUDITING
Documentation of continuing education is only required for recertification if a certified professional is randomly selected for
review, or audit of their education hours. Audits occur twice per year (every January and July).
Those selected for audit will be notified and must submit documentation of the appropriate number of hours of
education/training that they completed in the prior two-year period. Since the audit process is random, individuals may be
selected for audit multiple times.
Non-compliance with the required education/training for recertification is viewed as a breach of professional ethics.
DO NOT SEND IN COPIES OF YOUR CERTIFICATES OF COMPLETION FOR TRAININGS WITH YOUR RECERTIFICATION
APPLICATION. THESE WILL NOT BE REVIEWED AT THE TIME OF YOUR RECERTIFICATION AND WILL BE DISCARDED.
YOU WILL ONLY SEND COPIES OF TRAINING CERTIFICATES IF YOU ARE RANDOMLY SELECTED FOR A RECERTIFICATION
AUDIT.
EDUCATION INFORMATION
You can use the same education for multiple credentials under the following conditions: they are in the correct two-year
time frame (example if your credential was issued on 1/1/2017 and expires on 1/1/2019, you can use education after
1/1/2017) and it is relevant to the education requirements.
College/university course may be used. A three-college credit college course equals 45 hours.
Trainings, workshops, seminars, and conferences offered by professional associations, treatment providers, governmental
agencies may be used.
PCB does not accept general staff meetings, supervision, staff rounds, or case management as education.
Distance learning/online courses/webinars are acceptable. There is no limit to the number of distance learning/online
courses that can be used.
Acceptable documentation of education must include the professional’s name, title, date, number of hours and the
organization. Training registration forms and/or training sign-in sheets are not acceptable forms of documentation.
Training must be non-repetitive meaning the same training cannot be claimed more than one time even if the training is
taken on different dates from different providers.
Official employer training tracking system/learning management system reports may be acceptable forms of documentation
for education/training provided that the report contains the name of the employee/applicant, titles of each training, dates of
each training, the number of hours of each training, and is signed by the applicant’s supervisor.
Published work written by the certified professional and published by a professional publishing house may meet up to 10
hours of education. A copy of the published work must be submitted along with an education approval application.
A certified professional who provides education to other professionals may receive hours toward their own
recertification. The presenter will receive the same number of hours as the participant; and the presentation can be used
for credit once in each recertification period, provided the training has received PCB education approval. Training provided
by a certified professional must also be documented by sponsoring organization in the same manner as participant
documentation (i.e., certificate, letter of participation).
LAPSED CREDENTIAL
A credential is valid for a two-year period. If your credential lapses, you have 12 months from your expiration date to
recertify. After 12 months, you must reapply for your credential(s) and complete all the requirements for initial
certification. To renew a lapsed credential: complete the recertification application with the appropriate requirements
and fee(s), plus the lapsed fee of $100.
PCB Revised January 2021 3
FOR PROFESSIONALS HOLDING MULTIPLE PCB CERTIFICATIONS
If you have more than one credential, you pay the recertification fee for your original credential plus $50 each for all
other credentials you are recertifying. If your additional credentials do not have the same expiration date as your
primary credential, you will submit a second recertification application at the time they expire with the $50 per
credential recertification fee.
NAME CHANGES
Name changes can be made at any time. Official, legal documentation of the name change is required. A copy of the
legal documentation must be mailed, emailed, or faxed to PCB. Acceptable documentation includes copies of marriage
license, divorce decrees, etc. Names on certificates cannot be changed until documentation is provided. Once
documentation of a name change has been submitted to PCB, a new certificate will be sent to the certified professional.
EXPIRATION DATE CHANGE
If you hold multiple PCB credentials, you can request to change the expiration date(s) and recertify your credentials at
the same time. Recertification is made easier, as you are able to use the same education (if applicable) for all your
credentials. This is optional. A written request along with the fee of $25 per credential must be submitted with the
recertification application of your primary certification.
INACTIVE & EMERITUS STATUS
Inactive Status: For certified professionals, who are experiencing extenuating circumstances, a means to put their
certification on hold and avoid paying lapsed fees, retesting (if applicable) and the reapplication process. Inactive status is for
certified professionals who expect to be inactive for a minimum of six months. Insufficient hours of continuing education
will not be accepted as rationale for requesting Inactive Status.
Emeritus Status: For certified professionals who are retired from the work force but wish to maintain a connection to
PCB.
Approval of each status is at the discretion of PCB. Applicants will be notified by PCB of the approval or denial via email
approximately 7-10 business days after the request is received. For more information, visit www.pacertboard.org
and
click on Recertification. More information is on the left side of the page.
RELEASE
I hereby request that the Pennsylvania Certification Board grant the credential to me based on the following assurances
and documentation:
I subscribe to and commit myself to professional conduct in keeping with the PCB Code of Ethical Conduct;
I hereby certify that the information given herein is true and complete to the best of my knowledge and belief. I also
authorize any necessary investigation and the release of information relative to my certification. Falsification of any
records or documents in my application will nullify this application and will result in denial or revocation of certification;
I consent to the release of information contained in my application and any other pertinent data submitted to or
collected by PCB to officers, members, and staff of the aforementioned Board;
I consent to authorize PCB to gather information from third parties regarding continuing education and employment and
understand that such communication shall be treated as confidential;
Allegations of ethical misconduct reported to PCB before, during, or after application for certification is made will be
investigated by PCB and could result in the nullification of the application or denial or revocation of certification.
PCB Revised January 2021 4
RECERTIFICATION INFORMATION: RECOVERY & PEER CREDENTIALS
REQUIREMENTS AND FEES
RECOVERY & PEER SUPPORT CREDENTIALS
Name
Fee
Education Requirement
CRS
$100
30 hours relevant to recovery support services, including 6 hours in
ethics and 3 hours in confidentiality.
CFRS
$100
30 hours relevant to family recovery support services, including 6
hours in ethics and 3 hours in confidentiality.
CRSS
$100
Current and valid CRS/CFRS: 6 hours specific to the supervision of
recovery specialists. These hours may be included in the total (30)
hours needed to recertify the CRS/CFRS.
Non-CRS/CFRS: 30 hours of education including: 6 hours specific to
the supervision of recovery specialists, 6 hours in ethics, 3 hours in
confidentiality and 15 hours relevant to the field.
CPS
(Peer)
$50
36 hours of which 24 hours must be specific to peer support and/or
recovery practices, 3 hours in ethics, and the remaining 9 hours are
chosen by the professional and may be in any topic.
Are you recertifying your CPS and your CRS and/or CFRS at the same time?
• To determine your fee: look at your certificates and find your issue date. The credential you earned first, is your
primary credential. Find the fee for that credential above. You will pay that fee, plus $50 each for the other
credential(s) you hold. You will fill in payment information on the Recertification Payment Information Page
(page 8).
• You can use the same education for multiple credentials under the following conditions: they are in the
correct two-year time frame (example if your credential was issued on 1/1/2017 and expires on 1/1/2019, you
can use education after 1/1/2017) and it is relevant to the education requirements listed above.
Do you want your CPS and your CRS and/or CFRS to have the same expiration date?
You can do this simply by including a written request with your application and the fee on the Recertification Payment
Information Page (page 8). Your expiration date will change to your primary credential’s expiration date. To determine
this date in advance, look at your certificates and find your issue date. The credential you earned first, is your primary
credential.
PCB Revised January 2021 5
RECERTIFICATION INFORMATION: COUNSELOR, PREVENTION, ETC.
EDUCATION INFORMATION
1. PCB approval for all education.
2. Three (3) hours in professional ethics and responsibilities as part of the total education hours are required.
Acceptable trainings that would meet this requirement include but are not limited to: ethics related to human
services, HIPAA, confidentiality, boundaries, mental health law and mandated reporting.
3. Education that has not been previously PCB Approved must be submitted using the Education Approval Form
found on our website at www.pacertboard.org
.
4. PCB accepts education received outside of Pennsylvania under the following conditions:
a. Appropriate documentation (certificate, letter of attendance, transcript) is provided.
b. If an out-of-state education was approved by an IC&RC member board of that state, no further PCB
approval is necessary. Proof of the IC&RC member board approval must be submitted. If these
conditions were not met, the certified professional must seek PCB education approval.
REQUIREMENTS AND FEES
Name
Fee
Education Requirement
AAC
$100
40 hours relevant to addiction including 3 hours in ethics
CAAC, CADC & CAADC
$200
40 hours relevant to addiction including 3 hours in ethics
CCJP
$200
40 hours relevant to addiction including 3 hours in ethics
CCDP & CCDPD
$200
40 hours relevant to co-occurring disorders including 3 hours in ethics
CCS
$200
6 hours relevant to clinical supervision
ADDITIONAL CREDENTIALS
Name
Fee
Education Requirement
CPS (Prevention)
$200
40 hours relevant to prevention including 3 hours in ethics
CAAP
$125
25 hours relevant to addiction including 3 hours in ethics
CIP
$200
30 hours relevant to intervention including 3 hours in ethics
CCSM/CCMS
$200
40 hours relevant to addiction including 3 hours in ethics
CCHW
$75
30 hours relevant to community health including 3 hours in ethics
CDCORP
$75
2 deployments or exercises documented and five trainings
ENDORSEMENTS
Must be recertified at the same time as your qualifying credential. The hours to renew endorsement will be included in the
total hours needed to renew your qualifying credential.
Name
Fee
Education Requirement
Problem Gambling
$50
6 hours specific to gambling
Criminal Justice
$50
6 hours specific to criminal justice
Clinical Supervision
$50
6 hours specific to clinical supervision
PCB Revised January 2021 6
RECERTIFICATION APPLICATION: FOR ALL CREDENTIALS
Form can be completed and saved. You may then print the appropriate pages to submit to PCB.
TYPE OR PRINT LEGIBLY
PCB CERTIFICATION(S) I AM RECERTIFYING (CHECK ALL THAT APPLY):
Counselor: □ AAC □ CAAC □ CADC □ CAADC □ CCJP □ CCDP □ CCDPD □ CCS
Recovery & Peer Support: □ CRS □ CFRS □ CPS (Peer) □ CRSS
Prevention: □ CPS
Additional: □ CCSM □ CCMS □ CAAP □ CIP □ CDCORP □ CCHW
Endorsements: □ Gambling □ Criminal Justice □ Clinical Supervision
Date:
DOB:
□ Male
□ Female
□ Self-identify ___________________
Name:
SSN:
(last four)
Print your name as it should appear on your certificate. Credentials and degrees will not be printed.
Home Address:
City:
State:
Zip:
Cell Phone:
Email:
EMPLOYMENT INFORMATION Note: you do not need to be employed to recertify.
Position/Title:
Employer:
Employer City:
Zip:
Work Phone:
Ext:
1. Have you ever received any disciplinary action from another certification or licensing authority since
your last recertification? □ Yes □ No If yes, provide full details on a separate sheet.
2. Have you read and understood the PCB Code of Ethical Conduct? □ Yes □ No
The Code of Ethical Conduct is located at www.pacertboard.org, and click on Ethics.
3. Have you read and understood the Release? □ Yes □ No Located on page 4 of this application.
4. Have you read and understood the Auditing process (page 2)? □ Yes □ No
Military Experience: □ Not Applicable □ Active □ Veteran
Ethnicity: □ American Indian or Alaska Native □ Asian □ Black or African American □ Caucasian
□
Hispanic □ Latino □ Native Hawaiian or Other Pacific Islander □ Not specified: ______________________
What are your employment plans for the next two years? □ Increase Hours □ Decrease Hours
□
No Change □ Seek Advancement □ Retire □ Move to a different career □ Unknown
PCB Revised January 2021 7
EDUCATION & TRAINING
Candidates for recertification must list below all trainings attended in the two-year recertification period. Recertification
applications will not be approved without completion of the list. Photocopy this page if more room is needed. If the
organization or state agency from whom you received your trainings provide transcripts that lists your name, dates of
trainings, titles, and number of hours, you may submit that documentation in lieu of this form.
Title:
Hours:
Provider:
Date:
Title:
Hours:
Provider:
Date:
Title:
Hours:
Provider:
Date:
Title:
Hours:
Provider:
Date:
Title:
Hours:
Provider:
Date:
Title:
Hours:
Provider:
Date:
Title:
Hours:
Provider:
Date:
Title:
Hours:
Provider:
Date:
Title:
Hours:
Provider:
Date:
Title:
Hours:
Provider:
Date:
TOTAL NUMBER OF HOURS: ___________
I have attended all trainings listed above and will provide documentation of attendance if audited.
Applicant Signature
click to sign
signature
click to edit
PCB Revised January 2021 8
RECERTIFCATION PAYMENT INFORMATION
Payment in full must be made before recertification of a credential will be approved.
FEE CHECKLIST
Has your certification(s) lapsed? □ Yes □ No
If yes, fill in an additional $100 lapsed in the space provided below.
Recertification of primary credential: $________
(See Credentials table to the right for fee.)
Recertification of additional credential: $________
($50/additional credential if applicable.)
Lapsed $100 fee: $________
(If you checked yes to the above question, fill in the fee here.)
Education approval: $________
($10 or $20 if applicable. See Recertification Information page for more information.
This is not applicable to CPS (Peer), CRS, CRSS and CFRS.)
Expiration Date Change: $________
($25/per credential if applicable.)
TOTAL: $________
Payment (check one): □ Check □ Money Order □ VISA □ MasterCard □ Discover □ American Express
Checks & Money Orders made payable to PCB
Email address for receipt (if paying by credit card only): ______________________________________________________________
TO SUBMIT YOUR APPLICATION, CHOOSE ONE OF THE FOLLOWING:
• Mail: PCB, 298 S. Progress Avenue | Harrisburg, PA 17109
• Email: info@pacertboard.org NOTE: Only PDFs are acceptable. PCB does not accept photos of applications.
• Fax: 717-540-4458
Please allow 5-10 business days for review and processing of your recertification application.
To confirm receipt of your application, or check on the status, you must email info@pacertboard.org.
CREDENTIALS &
ENDORSEMENTS
CRS
$100
CFRS
$100
CPS (Peer)
$50
CRSS
$100
AAC
$100
CAAC, CADC & CAADC
$200
CCJP
$200
CCDP & CCDPD
$200
CCS
$200
CPS (Prevention)
$200
CAAP
$125
CIP
$200
CCSM/CCMS
$200
CCHW
$75
CDCORP
$75
Problem Gambling
$50
Criminal Justice
$50
Clinical Supervision
$50
Number:
-
-
-
Sec. Code:
Exp. Date:
Name on Card:
Billing address:
(If different than Home Address)
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Completed 3 June 2021

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