Fillable Grandfathering (GF) Criteria for Community Health Worker (CHW) (Missouri Credentialing Board)

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Grandfathering (GF) Criteria for Community Health Worker (CHW) (Missouri Credentialing Board)

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Revised May 2020 CHW GF Application Page 1
Missouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
Grandfathering (GF) Criteria for Community Health Worker
(CHW)
I. Criteria
Minimum of HS Diploma/HSE
Completion of DHSS approved CHW Standard Training Program OR
800 hours of CHW experience within the last 3 years of applying
CHECK LIST FOR CHW GF APPLICATION
1. You have submitted a $50.00 check with this application or have provided your credit/debit card
information on page 4 of this application packet. Applications will not be reviewed until payment is
received.
2. You have completely filled out the application.
3. You have signed the Code of Ethics.
4. You have filled out the Family Care Safety Registry Worker Registration Form and included the form
with your packet. 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.
5. The appropriate documentation was sent to verify the required educational/training program or the 800
hours of work experience.
6. The appropriate High School/HSE or College transcripts were sent.
10 Typically, applications are reviewed within two weeks of receipt in the MCB office. If you have not
received written or e-mail correspondence from the MCB 3 weeks after mailing your application to the
MCB, call the MCB.
11 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 your
certificates will be mailed soon.
Revised May 2020 CHW GF Application Page 2
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 most recent application packet. If you are unsure, contact the MCB office.
2. The application must be typed or neatly printed.
3. Please keep a copy of all materials submitted for your records.
4. FEES: The total CHW GF Fee is $50.00. You may pay by check, money order, or provide credit card
information on page 4 of this application packet. Applications will not be reviewed until payment is
received.
5. Please be aware that should your application be reviewed and additional information is requested to
complete the application, you will have 90 days to provide the requested information. Failure to do so
will result in your application expiring without being approved.
6. All fees are non-refundable. If your application is denied or expires, fees will not be refunded.
7. If your application is denied, you may contact the MCB office staff for instructions on how to appeal the
denial of your application.
8. All materials submitted to the MCB office become property of the MCB.
9. The applicant must currently reside and/or work/volunteer 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.
10. If at any time during the credentialing process, a question arises about an applicant’s moral character,
reputation for honesty, integrity, or professionalism, the Board may either deny the application at that
time or place the application on hold until an investigation has been completed and a decision made
regarding the question brought up.
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 the MCB. Please do not fax or e-mail your application.
Revised May 2020 CHW GF Application Page 3
Important Notice To Applicants
According to Missouri Credentialing Board (MCB) Policies and Procedures, the following rules apply to those
seeking a MCB credential.
1. The following items disqualify an individual from obtaining the CHW 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.
2. If an individual has applied for and been given an exception from the CHW Association, the individual
may apply for a MCB credential. Please send in proof of exception with your application.
3. If an individual was denied an exception from the CHW Association and would still like to be
credentialed, the individual may apply directly to the Missouri Credentialing Board exceptions
committee.
Revised May 2020 CHW GF Application Page 4
GRANDFATHERING APPLICATION
FOR
Community Health Worker (CHW)
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 May 2020 CHW GF Application Page 5
THIS APPLICATION MUST BE TYPED OR PRINTED NEATLY
All Applications Become the Property of MCB
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 by the MCB or 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 CHW Association or
the MCB Exceptions Committee. (If you have already completed the Exceptions Process, you do not need to
complete the Felony Offense Form)
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 May 2020 CHW GF Application Page 6
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
Training Requirements
A. Submit documentation of the completed required DHSS approved CHW training program OR
B. Documentation of 800 work experience hours obtained within the last 3 years which should be
documented on the Work/Volunteer page of this application.
Revised May 2020 CHW GF Application Page 7
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
(ATTACH COPY OF SOCIAL
SECURITY CARD)
- -
DATE OF BIRTH
/ /
GENDER
MALE
FEMALE
TELEPHONE NO.
(OPTIONAL)
( )
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 authorized 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.
Revised May 2020 CHW GF Application Page 8
Applicant’s Agreement to the Code of Ethical Practice and Professional Conduct
I have read the current Community Health Worker’s Ethics Code as listed on the MCB web site
www.missouricb.com
, MCB Ethics Code Link and agree to abide by this code:
Print 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.
Print Name Date
Signature Date
Revised May 2020 CHW GF Application Page 9
Missouri Credentialing Board
428 E. Capitol, 2
nd
Floor, Jefferson City, MO 65101
WORK/VOLUNTEER VERIFICATION FORM
An applicant is applying to the MCB for a Community Health Worker Credential. Please complete this form
and provide a copy to the applicant to include with their application.
Applicant’s Name: _____________________________________________________________________________
Supervisor's Name (Print):________________________________________________________________________
Organization Name: _____________________________________________________________________________
Address: _____________________________________________________________________________________
_____________________________________________________________________________________________
Telephone: ___________________________________________________________________________________
E-mail: _______________________________________________________________________________________
Today’s Date: _________________________________________________________________________________
Within the last 3 years from the date listed above, please list the composite total number of hours the
applicant spent working with clients in the role of a Community Health Worker. This work can be paid work or
volunteer work:
Community Health Worker: ____________________________________________________________
Supervisor's Name (Printed): ___________________________________________________________________
Supervisor’s Signature: ________________________________________________________________________
Date: ______________________________________________________________________________________
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Grandfathering (GF) Criteria for Community Health Worker (CHW) (Missouri Credentialing Board)

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Completed 28 August 2020

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