Fillable Department of Fire Services - Application Request for Fire Prevention Officer Re-Credential - Level I SAMPLE

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Department of Fire Services - Application Request for Fire Prevention Officer Re-Credential - Level I SAMPLE

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MARCH 2019
MASSACHUSETTS
FIREPREVENTIONOFFICER
RE‐CREDENTIAL
LEVELI
(FPOI)
COMMONWEALTHOFMASSACHUSETTS
Submit Completed Applications to: DFS.credentialing@mass.gov
HARD COPY APPLICATIONS WILL NOT BE ACCEPTED
Department of Fire Services
Fire Prevention Officer Re-Credential
APPLICATION REQUEST FOR FIRE PREVENTION OFFICER RE-CREDENTIAL – LEVEL I
Name _______________________________________________________________________________________________
Department ___________________________Current Position/Rank ____________________ Years in Position _________
Daytime Phone _____________________________Email_____________________________________________________
Work Address________________________________________________________________________________________
City, State, Zip ____________________________________________________________________________________
Date of Last Credential _____ / _____ /_____ Expiration Date of Last Credential _____ / _____ /_____
Date
of Application Submitted _____ / _____ /_____
(Must match date of submission email )
A COMPLETED APPLICATION INCLUDES:
Signed Credential Commitment
Formal Education Score Card Formal Education____ points (max = 20)
College Degree or Certificate Attached
Certifications and Exams Score Card Fire Certs/Exams ____ points (max = 20)
Proof of Certifications Attached Other Certs/Exams ____ points (max = 10)
Professional Memberships Score Card Membership____ points (max = 5)
Proof of Membership Attached
Boards/Commissions/Technical Committees Score Card
Boards/Commissions____ points (max = 12)
Professional Development Score Card Professional Development____ points (max = 35)
Transcripts or Course Certificates Attached
Fire Prevention Work Experience Score Card Fire Prevention ____ points (max = 6)
Al
l supplemental verification documents should be at the end of the document or in 1 additional separate file.
YOUR ______POINTS
TOTAL REQUIRED FOR FPO-I 36 POINTS
(D
FS Use Only)
Denied App
roved
Name/Title _________________________________Authorized Signature __________________________ Date_________ Approval # _______________
LMS STUDENT ID
JOHN SMITH
ANYTOWN FIRE
CAPTAIN
5
555-555-5555
JOHNSMITH@EMAIL.COM
ANYTOWN MA 01775
03
15
12
31
18
02
01
01
18
✔
✔
✔
✔
✔
✔
✔
3
✔
0
✔
10
2
✔
8
10
✔
6
39
Department of Fire Services
Fire Prevention Officer Re-Credential
An individual wishing to maintain the Fire Prevention Officer Credential – Level I will be required to accumulate
36 points of approved attendance/activities in a consecutive 36-month period that begins on the date of issuance
of the Fire Prevention Officer Credential.
An individual wishing to maintain the Fire Prevention Officer Credential – Level II will be required to accumulate
72 points of approved attendance/activities in a consecutive 36-month period that begins on the date of issuance
of the Fire Prevention Officer Credential.
In the event a previously credentialed individual fails to acquire the minimum points in the consecutive 36-month
period the Fire Prevention Officer Credential shall become void.
An individual previously awarded credential by the State Fire Marshal who has allowed it to expire, and wishes to
have the credentialing reinstated will be required to comply with the current minimum standards established for
“re-credentialing”.
Minimum standards are defined as: accumulating the required points of approved attendance/activities in a
consecutive 36-month period from the date of the submitted application and not prior to the initial credential date.
Credential Commitment
I understand that credentialing is subject to the approval of the State Fire Marshal. I will execute
the necessary documents and supply further information as determined by The State Fire
Marshal. I understand that any false statements or misrepresentation submitted in the course of
these proceedings may result in the revocation of any credentialing.
I hereby attest that I am currently an active member of the Massachusetts Fire Service and give permission for
verification of any information provided in this application.
Sign____________________________________________________ Date___________________
Credentialing is valid for 3-years.
The Continuing Education component is designed to encourage that new achievement is made during each
consecutive 3-year period. This includes remaining current and active with organizations and committees and by
keeping your certifications current, if they require continuing education. The goal is to assist the credentialed Fire
Prevention Officer in maintaining a higher level of professionalism within the fire service after initial
credentialing.
JOHN SMITH
01/01/18
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Department of Fire Services
Fire Prevention Officer Re-Credential
FORMAL EDUCATION
College Degree or Certificate Attached
College degrees can be in any subject for credit. No credit for partial completion of degree requirements will be
awarded. All degrees or course work must be from an accredited college or university.
Credit for degrees or college certificate will only be awarded if earned during the consecutive 3-year period since
last credential or application date if expired.
Choose ONLY highest level attained for maximum points.
CRITERIA POINTS
DATE (S)
YOUR POINTS
MAX
20
College Certificate
3
Associates Degree
5
Bachelors Degree
10
Masters Degree
15
Doctorate PhD
20
JOHN SMITH
✔
3
2016
3
Department of Fire Services
Fire Prevention Officer Re-Credential
CERTIFICATIONS AND EXAMS
Proof of Certifications Attached
Certifications can be issued by Federal, State, or NFPA.
***LIST ONLY EXAMS IN THIS SECTION***
Credit for fire examinations will only be awarded if a passing score is achieved and earned during the consecutive
3-year period since last credential or application date if expired.
Choose ONLY highest level attained for maximum points.
FIRE OFFICER CERTIFICATIONS AND EXAMS
CRITERIA POINTS
DATE
YOUR POINTS
MAX
20
Fire Officer I or Fire Lieutenant
5
Fire Officer II or Fire Captain
10
Fire Officer III or Deputy/District/Assistant Chief
15
Fire Officer IV or Chief of Department
20
OTHER CERTIFICATIONS AND EXAMS
CRITERIA POINTS
DATE
YOUR POINTS
MAX
10
Fire Inspector I
5
Fire Inspector II
10
Fire Inspector III
15
Fire Instructor I
5
Fire Instructor II
10
Fire Instructor III
15
Fire Investigator
10
Hazardous Materials: Operations
5
Hazardous Materials :Technician
10
Incident Safety Officer
10
Public Fire and Life Safety Educator I
5
Technical Rescuer: Confined Space Rescue I/II
5
Technical Rescuer: Rope Rescue I/II
5
Technical Rescuer: Trench Rescue I/II
5
JOHN SMITH
✔
5
10
2015
5
2016
5
Department of Fire Services
Fire Prevention Officer Re-Credential
PROFESSIONAL MEMBERSHIPS
Membership Cards or a Letter Acknowledging Acceptance of Membership Attached
Only active membership in fire, rescue, or emergency management organizations will be accepted.
Local, county, state, regional, and international organizations are accepted.
Examples of approved memberships include: the Fire Prevention Association of Massachusetts, International
Association of Arson Investigators, NFPA and District Organizations.
The applicant must be a member during the consecutive 3-year period since last credential or application date if
expired.
CRITERIA POINTS
YOUR POINTS
MAX
5
1 Point Per Year Per Membership
List Dates (YYYY-YYYY)
JOHN SMITH
✔
2
FPAM
2015-2017
2
Department of Fire Services
Fire Prevention Officer Re-Credential
BOARDS/COMMISSIONS/TECHNICAL COMMITTEES
Examples of approved organizations include: Board of Fire Prevention Regulations, Hazardous Materials
Advisory Board, 9-1-1 Commission, Massachusetts Homeland Security Councils, NFPA Technical Committees,
City/Town Committees, etc.
The applicant must be a member during the consecutive 3-year period since last credential or application date if
expired.
CRITERIA POINTS
YOUR POINTS
MAX
12
4 Points Per Year Per
Board/Commission/Technical Committee
List Dates (YYYY-YYYY)
JOHN SMITH
8
BOARD OF FIRE PREVENTION REGULATIONS
2015-2017
8
Department of Fire Services
Fire Prevention Officer Re-Credential
PROFESSIONAL DEVELOPMENT
ALL trainings included below MUST have been evaluated for credit and appear on the Approved Trainings List
with an Approval #.
I
f there is a training that does not appear on the
Approved Trainings List with credit or you would like to challenge
the awarded credit, you MUST submit a
Training Request for Credit Application and receive an Approval # prior
to including the training in this application.
As of 01/01/18, Th
e Massachusetts Firefighting Academy course, NC2, is required for re-credential.
C
redit is only awarded for trainings taken during the consecutive 3-year period since last credential or application
date if expired.
Y
ou can NOT include the original Fire Prevention Officer course you completed in order to attain your current
credential.
Education Transcripts or Certificates Attached
APPROVAL
#
TRAINING PROGRAM TITLE
(EXACTLY AS LISTED ON APPROVED LIST)
CRITERIA
POINTS
YOUR
POINTS
MAX
35
List Date(s)
JOHN SMITH
✔
✔
10
NC2
New Fire Code Orientation - 527 CMR 1.00 2015 Updates
12/1/17
3
960
Nightclub Fire Safety
01/24/17
7
Department of Fire Services
Fire Prevention Officer Re-Credential
FIRE PREVENTION OFFICER WORK EXPERIENCE
The candidate must be a member in good standing of a Fire Department or Fire District
I am a member in good standing of a fire department or fire district.
Credit is awarded for work experience during the consecutive 3-year period since last credential or application
date if expired.
CRITERIA POINTS
YOUR POINTS
MAX
6
2 Point Per Year Served
List Dates (YYYY-YYYY)
JOHN SMITH
✔
6
2015-2018
6
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Department of Fire Services - Application Request for Fire Prevention Officer Re-Credential - Level I SAMPLE

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Completed 15 May 2020

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