Fillable Knowledge/ Skill Exams (Pennsylvania Certification Board)

Fill Online, Printable, Fillable, Blank Knowledge/ Skill Exams (Pennsylvania Certification Board) Form

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

Knowledge/ Skill Exams (Pennsylvania Certification Board)

On average this form takes 24 minutes to complete

The Knowledge/ Skill Exams (Pennsylvania Certification Board) form is 16 pages long and contains:

  • 2 signatures
  • 27 check-boxes
  • 75 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Pennsylvania Certification Board forms online.

BROWSE PENNSYLVANIA CERTIFICATION 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
 
PCB CFRS Application | Revised January 2021
APPLICATION INSTRUCTIONS – READ CAREFULLY
Prior to applying, all requirements must be met and documented.
Do not apply until all requirements are met.
TO SUBMIT AN APPLICATION, CHOOSE ONE OF THE FOLLOWING:
1. Mail: PCB, 298 S. Progress Avenue, Harrisburg, PA 17109
2. Email: info@pacertboard.org NOTE: Only PDFs are permitted. Photos of applications are not accepted.
3. Fax: 717-540-4458 NOTE: faxing is an unreliable technology. Receiving a confirmation of fax does not
indicate it has been received. To confirm receipt of application, email info@pacertboard.org
.
REVIEW & APPROVAL PROCESS
1. Application submitted to PCB. To confirm receipt of application, email PCB at the above email address.
2. Staff reviews application. Allow up to 10 business days for review and processing.
3. Applicant will be emailed if there is any documentation missing or there are questions regarding an
application. Applications with pending problems will be held open for one year from date of receipt
after which they will be closed.
4. If you have not heard from PCB regarding your application after 10 business days, email
info@pacertboard.org
.
5. A certificate will be mailed to you within 10 business days.
CFRS APPLICATION
Certified Family Recovery Specialist
PCB CFRS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
2
CERTIFIED FAMILY RECOVERY SPECIALIST REQUIREMENTS
All requirements below must be met to apply. All required documentation must be sent in with an application
except for the official college transcript which is sent to PCB directly prior to application.
FORMAL EDUCATION
REQUIRED: Minimum high school diploma/GED.
Veterans may provide discharge documentation in lieu of a high school diploma/GED.
A copy of the high school transcript or diploma is acceptable or GED verification. If the school is from outside the
United States, an equivalency must be done by an organization that specializes in that process. The applicant is
responsible for arranging this process and all costs.
It is recommended you obtain documentation approximately three weeks prior to sending in your application.
Documentation of high school/GED can be included with your application or can be mailed to PCB or emailed
to info@pacertboard.org
by the educational institution prior to application.
College degree documentation can be used in lieu of a high school diploma/GED. The degree must be from an
accredited college/university that is recognized by the US Department of Education or the Council on Higher
Education Accreditation. An official transcript sent directly from college/university is required. If the degree is
from outside the United States, a degree equivalency must done by an organization that specializes in that
process. The applicant is responsible for arranging this process and all costs.
Official transcripts are required and must be sent directly from college/university to PCB prior to application.
Official transcripts may be mailed to PCB or emailed to info@pacertboard.org
.
It is recommended you request transcripts approximately three weeks prior to sending in your application.
If you have a sealed official transcript in your possession, you may mail it in the sealed envelope to PCB prior to
your application arriving or mail it in with your application.
If you have outstanding debt or other issues which prevent the college/university from releasing your official
transcript, you must resolve these issues with the school prior to applying for certification.
TRAINING
REQUIRED: 78 hours of mandatory, standardized recovery specialist training.
A list of approved statewide trainers authorized to provide the 78-hour mandatory, standardized recovery
specialist training can be found on the PCB website. All education/training must be documented.
The required mandatory, standardized training is documented with a copy of the completed training certificate.
PCB CFRS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
3
PERSONAL, LIVED FAMILY RECOVERY EXPERIENCE
REQUIRED: The CFRS credential is for adults who have been directly impacted by their own
family member or loved one’s substance use disorder.
STATEMENT OF LIVED EXPERIENNCE
REQUIRED: A minimum 1000-word essay describing the impact your own family member
or loved one with a substance use disorder had on you.
LETTERS OF REFERENCE/CHARACTER
REQUIRED: Three letters of reference/character.
CERTIFICATION FEE
REQUIRED: $150.00
(fee must accompany certification application)
The fee may be paid by check, money order or with VISA, MasterCard, Discover or American Express.
If an employer or organization is paying the fee, they must include the applicants name with the payment.
Fee payment information provided on page 6 of this application. E-receipts will be sent if using a credit card for
payment. Receipts for check or money order payments must be requested by applicant to PCB.
Applications received without payment will not be processed.
Office of Vocational Rehabilitation (OVR) Payments: PCB is an approved vendor of OVR. If OVR is paying for your
application fee, it highly recommended payment processing is initiated at least three weeks prior to application
submission. CFRS applications will not be approved until payment is received. Delay in payment can significantly
delay the application process.
One-half of the fee is refundable if application is denied.
PCB CFRS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
4
APPLICATION INFORMATION
GENERAL INFORMATION
Email addresses provided to PCB must be active accounts that are checked regularly. We will not be able to contact
you without an email address. Please print legibly.
Applicants must either live or work in PA at the time of application.
This certification is a non-reciprocal credential recognized and used only in PA.
APPEAL PROCESS
The purpose of appeal is to determine if PCB accurately reviewed an application that is denied. A letter
requesting an appeal must be sent to PCB within 30 days of the notification of PCB's action. An applicant shall be
considered notified three days after the relevant date of mailing. The appeal will be sent to the PCB Executive
Committee who will thoroughly review the entire application and materials to determine whether or not
applicant should have been denied approval. The applicant will be notified in writing as to the findings of the
Executive Committee.
FELONIES & DISCIPLINARY ACTIONS
While felonies and disciplinary actions from other certification/licensing entities may not prohibit certification,
documentation is required to be submitted at the time of application. Certification through PCB does not mean
a professional should not disclose this information to potential employers and does not in any way exonerate
charges.
REQUESTS TO CHANGE APPLICATION
Professionals who wish to have their application re-reviewed for another credential PCB offers will incur a $50
application change/review fee.
CERTIFICATION TIME PERIOD
Certification encompasses two calendar years beginning on the date the application is approved. The certificate
issued to the professional lists the following information: name of professional, credential name, date of issue,
date of expiration and certification number.
RECERTIFICATION
To maintain the high standards of professional practice and to assure continuing awareness of new knowledge
in the field, the Board requires recertification every two years. Professionals should review the Recertification
Application for credential specific requirements listed on the Board website well in advance of their expiration
date.
PCB CFRS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
5
CFRS APPLICANT INFORMATION & PAYMENT
Application can be completed and saved. You may then print the appropriate pages to submit to PCB.
TYPE OR PRINT LEGIBLY
Date:
DOB:
□ Male
□ 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:
Primary Email:
PRINT LEGIBLY: EMAIL IS OUR PRIMARY WAY OF COMMUNICATING WITH YOU.
Secondary Email:
PRINT LEGIBLY: EMAIL IS OUR PRIMARY WAY OF COMMUNICATING WITH YOU.
Have you ever received any disciplinary action from another certification/licensing authority? □ Yes □ No
If yes, provide full details on a separate sheet.
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.
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: ______________________
Employment plans for the next two years: □ Increase hours □ Decrease hours □ No change □ Seek advancement
□ Retire □ Move to a different career □ Unknown
PAYMENT INFORMATION
FEE OF $150 CAN BE PAID USING ONE OF THE FOLLOWING (CHECK ONE):
□ Check □ Money Order □ VISA □ MasterCard □ Discover □ American Express
Checks & Money Orders made payable to PCB
□ My employer/organization is mailing payment directly to PCB.
Email for receipt (if paying by credit card only): ________________________________________________________________
Number:
-
-
-
Sec. Code:
Exp. Date:
Name on Card:
Billing address:
(If different than Home Address)
PCB CFRS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
6
CFRS: FORMAL EDUCATION AND REQUIRED TRAINING
REQUIRED: Minimum high school diploma/GED.
I am documenting my high school diploma/GED.
□ Yes □ No
I am documenting my college degree.
□ Yes □ No
College/University:
Name on Transcript:
Date Transcript Requested:
Delivery Method:
□ Mailed to PCB
□ Emailed to PCB
REQUIRED: 78-hour mandatory, standardized recovery specialist training.
I have included a copy of my training certificate for the 78-hour mandatory, standardized recovery specialist training
with this application.
□ Yes
□ No
PCB CFRS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
7
CFRS: WORK/VOLUNTEER EXPERIENCE
Work/volunteer experience is not a requirement to obtain the CFRS. However, please complete
this page if you are employed or volunteer in the behavioral health field.
CURRENT EMPLOYMENT/VOLUNTEER INFORMATION
Employer Name:
How many hours do you work/volunteer per week? ______________________________________________________
Total hours/years worked in current position? ___________________________________________________________
Employer City:
Zip:
Applicant Position/Title:
Start Date in Current Position:
PCB CFRS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
8
CFRS: ATTESTATION, STATEMENT OF LIVED EXPERIENCE, & LETTERS OF
REFERENCE/CHARACTER
REQUIRED: Signed attestation below of your own lived experience as a family member or loved one
of a person or persons with a substance use disorder.
I attest that I have been directly impacted by a direct family member or loved one of mine with a substance use
disorder and will share my lived experience with other families to provide recovery support services.
__________________________________________ _____________________________
Applicant Signature Date
REQUIRED: A minimum 1000-word essay describing the impact your own family member or loved
one with a substance use disorder had on you, your experience navigating multiple systems,
describing how your experience informs your work with other families, what resources you have
accessed, and what family recovery means to you. You should also describe how long you have
considered yourself in recovery.
I have included a minimum 1000-word essay including all components described above.
□ Yes
□ No
REQUIRED: Three letters of reference/character.
Applicants must submit three (3) letters of reference/character. Letters may not be from their own family members. Letters
should show the impact the applicant has made to the field. They should also include how the applicant practices self-care,
how they have developed boundaries and how they work with other families. The letters of reference/character must be
from each of the following areas:
• letter of reference/character: personal (1)
• letter of reference/character: professional/volunteer (1)
• letter of reference/character: within recovery support services (1)
I have included three letters of reference/character as described above.
□ Yes
□ No
PCB CFRS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
9
CFRS: ACKNOWLEDGEMENTS & RELEASE
This page must be completed by the applicant. It must be notarized and submitted with the application.
RELEASE
I request that the Pennsylvania Certification Board (PCB) 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 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 application;
• Falsification of any documents 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 education, employment and/or
supervision 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.
INITIAL EACH STATEMENT
I have read and understood this Acknowledgements and Release.
I either live or work in Pennsylvania at least 51% of the time.
I understand one-half of the application fee is refundable if application is denied.
I understand that my application is open for a period of one year after the date of review. If I fail to fulfill all
certification requirements within that year, the application will be closed, and no refund will be issued.
I understand that if I request to have my application re-reviewed for another credential PCB offers,
I will incur a $50 change/review fee.
Applicant:
Signature:
Date:
PRINT NAME LEGIBLY
NOTARY PUBLIC ONLY
Name:
Date:
I attest that I am a notary public and the above-named applicant satisfactorily proved to be the person whose name is
subscribed to the within instrument and acknowledged that they executed the same for the purposes therein contained.
In witness whereof, I hereby set my hand and official seal.
__________________________________________________ SEAL:
Notary Public Signature
click to sign
signature
click to edit
PCB CFRS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
10
CFRS: CHECKLIST
Applicant Name:
Page must be completed and submitted with the application. Do not submit your application until checklist is reviewed,
completed and all documentation is compiled.
Prior to applying, all requirements must be met and documented. Use the table below as a guide for gathering
documentation.
Do not submit any documentation with an application that is not listed on the table or the application
unless specifically instructed by a staff member. Do not apply until all requirements are met.
TO SUBMIT AN APPLICATION, CHOOSE ONE OF THE FOLLOWING:
1. Mail: PCB, 298 S. Progress Avenue, Harrisburg, PA 17109
2. Email: info@pacertboard.org NOTE: Only PDFs are permitted. Photos of applications are not accepted.
3. Fax: 717-540-4458 NOTE: faxing is an unreliable technology. Receiving a confirmation of fax does not indicate it has been
received. To confirm receipt of application, email info@pacertboard.org
.
I acknowledge, that to the best of my ability, I have submitted a completed application.
Signature:
Date:
REQUIREMENT DOCUMENTATION
✓
Application page with payment
• Page 5
Formal Education & Training page
• Page 6
Education
• High School Diploma/GED/college transcripts
or diploma
• Copy of training certificate
Relevant Work Experience
• Page 7
Attestation, essay, letters of reference
• Page 8
Notarized Acknowledgement & Release page
• Page 9
Checklist page
• Page 10
Disciplinary Actions?
• Include letter of explanation with application
Convicted of a felony?
• Include letter of explanation with application
Company paying fee?
• Include applicant name on payment
Copy entire application for records
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

Knowledge Skill Exams (Pennsylvania Certification 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 3 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document