Fillable Missouri Credentialing Board Criteria For Missouri Advanced Prevention (Missouri Credentialing Board)

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Missouri Credentialing Board Criteria For Missouri Advanced Prevention (Missouri Credentialing Board)

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Revised August 2019 MAPS Application 1
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 Missouri Advanced Prevention Specialist (MAPS)
Missouri Advanced Prevention Specialist
• Hold a Certified Reciprocal Prevention Specialist Credential
• HS Diploma/HSE & 10,000 hours prevention work experience within the
last 10 years or
• Bachelor Degree & 8,000 hours prevention work experience within the last
10 years or
• Master Degree & 6,000 hours prevention work experience within the last
10 years
•
A degree must be obtained 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.
DEFINITIONS
A. 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 worked.
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.
Revised August 2019 MAPS Application 2
CHECK LIST FOR MAPS APPLICATION
1. You have submitted the $110.00 with this application or have provided your credit card information on
page 5 of this application packet. Applications will not be reviewed until payment is received.
2. You have filled out the Family Care Safety Registry Worker Registration Form and returned it with this
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.
3. You have completely filled out the application.
4. You have signed the Code of Ethical Practice/Professional Conduct and Authorization and Release.
5. The appropriate person has completed and signed the Prevention Professional Employment Verification
Form(s) and you have included the completed form with the application.
6. The appropriate High School/HSE or college transcripts were included.
7. 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
8. 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.
Revised August 2019 MAPS Application 3
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. Please keep a copy of all materials submitted for your records.
4. FEES: The total MAPS Fee is $110.00. You may pay by check, money order, or by providing credit card
information on page 5 of this application packet. Applications will not be reviewed until payment is
received.
5. 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.
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 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.
10. 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 either 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.
11. Please note that this credential is only valid in the State of Missouri.
12. Please remember 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.
13. Please mail your application to us. Please do not fax or e-mail your application.
Revised August 2019 MAPS Application 4
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 MAPS Application 5
APPLICATION
FOR
Missouri Advanced Prevention Specialist (MAPS)
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 MAPS Application 6
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: _________/_________________ 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 MAPS Application 7
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
Revised August 2019 MAPS Application 8
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 MAPS Application 9
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 Missouri Advanced
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 MAPS Application 10
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.
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