Fillable PCB CCHW Application 19 (Pennsylvania Certification Board)

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PCB CCHW Application 19 (Pennsylvania Certification Board)

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The PCB CCHW Application 19 (Pennsylvania Certification Board) form is 9 pages long and contains:

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  • 33 check-boxes
  • 75 other fields

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PCB CCHW Application | Revised September 2020
298 S. Progress Avenue, Harrisburg, PA 17109
Phone: 717-540-4455 Fax: 717-540-4458
www.pacertboard.org info@pacertboard.org
CCHW APPLICATION
Certified Community Health Worker
LEGACY APPLICATION
January 1, 2020 – June 30, 2021
PCB CCHW Legacy Application | www.pacertboard.org | info@pacertboard.org | Revised September 2020
2
APPLICATION INSTRUCTIONS – READ CAREFULLY
Prior to submitting your application, you must have all requirements completed and
documented. Use the table below as a guide for gathering your documentation.
Do not submit any documentation with your application that is not listed on the table or the
application unless specifically instructed by a staff member. Do not submit your application
until you have completed the application requirements.
REQUIREMENT DOCUMENTATION
✓
Application Page with payment
• Page 7
Experience & Supervision Information
• Page 8
• Previous relevant employment documentation
(if needed).
Current Volunteer/Job Description
• Obtain from organization.
Supervision Documentation Form
• Page 9
Education
• Copies of trainings
Acknowledgement & Release
• Page 10, notarized
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
TO SUBMIT YOUR 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 your application, email info@pacertboard.org
.
REVIEW & APPROVAL PROCESS
1. Application submitted to the Board. To confirm receipt of your application, you must email the
Board at the above email address.
2. Staff reviews application. Allow 5- 10 business days for review and processing of your
application.
3. Applicant will be emailed if there is any documentation missing from the application or there
are questions regarding your application. It is imperative that you write your email legibly.
4. If you have not heard from the Board regarding your application, check the Credential Search on
the website. If your name does not appear after 10 business days, email info@pacertboard.org
.
5. A certificate will be mailed to you automatically within 5-10 business days.
PCB CCHW Legacy Application | www.pacertboard.org | info@pacertboard.org | Revised September 2020
3
APPLICATION INFORMATION
APPEAL PROCESS IF APPLICATION IS DENIED
The purpose of appeal is to determine if the Board accurately, adequately and fairly reviewed an
application that is denied. A letter requesting an appeal must be sent to the Board in writing within 30
days of the notification of the Board's action. An applicant shall be considered notified three days after
the relevant date of mailing. The written appeal will be sent to the Executive Committee who in turn 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.
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.
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
the Board 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 the Board offers
prior to taking the examination, or after an unsuccessful attempt at the examination will incur a $50
application change/review fee.
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 CCHW Legacy Application | www.pacertboard.org | info@pacertboard.org | Revised September 2020
4
ROLE OF THE COMMUNITY HEALTH WORKER
A Community Health Worker (CHW) is a trusted individual who contributes to improved health
outcomes in the community. CHWs serve the communities in which they reside or communities with
which they may share ethnicity, language, socioeconomic status, or life experiences. The term
“community health worker,” includes but is not limited to other titles such as outreach worker, patient
navigator and promotores de salud.
A CHW proactively:
• builds individual and community capacity by increasing health knowledge and self-sufficiency
through a range of activities such as outreach, community education, informal counseling, social
support and advocacy;
• serves as a liaison between communities and health care agencies;
• provides guidance and social assistance to community residents;
• enhances community residents’ ability to effectively communicate with healthcare providers;
• provides culturally and linguistically appropriate health education;
• advocates for individual and community health;
• provides referral and follow-up services or otherwise coordinates care; and
• identifies and helps enroll eligible individuals in federal, state, and local private or nonprofit
health and human services programs.
CERTIFIED COMMUNITY HEALTH WORKER REQUIREMENTS
Prior to submitting your application, applicants must have all requirements completed and documented.
EXPERIENCE & SUPERVISION
Qualifying experience is based upon an individual providing services that are specific to the community
health worker domains.
Only employment within the last five (5) years may be counted towards the total experience
requirement.
If the applicant’s experience requirement is not fulfilled from their current employer, they must include
a letter (on company letterhead) from previous employer(s) verifying their duties and dates employed
with their application.
• Experience: one (1) year of full-time volunteer or paid employment or 2000 hours of part-time
of volunteer or paid employment.
Supervision is a formal or informal process that is evaluative, and supportive. It can be provided by more
than one person, it ensures quality of services, and extends over time. Supervision includes observation,
mentoring, coaching, evaluating, inspiring, and creating an atmosphere that promotes self-motivation,
learning, and professional development. In all aspects of the supervision process, ethical and diversity
issues must be in the forefront.
• Supervision: 60 hours specific to the domains. Hours may be included in the total experience
requirement.
PCB CCHW Legacy Application | www.pacertboard.org | info@pacertboard.org | Revised September 2020
5
CURRENT VOLUNTEER/JOB DESCRIPTION
All applicants must include their current job description with their application. This document is
provided by your employer and must be signed and dated by you and your supervisor. Job descriptions
are reviewed as a part of experience verification. If your supervisor does not have your job description,
you should contact your organization’s Human Resource department. The Board does not provide the
job description.
• Current volunteer/job description: obtained from employer.
EDUCATION
Education is defined as formal, structured instruction in the form of workshops, trainings, seminars, in-
services, college/university credit courses and online education. If you provide this type of education to
other professionals, you may use it towards the education requirement with documentation from the
organization or college/university. Most three-credit college/university courses are 45 hours. There is no
time limit on the use of education for initial certification.
Education review is available prior to application submission with the use of the Education Review Form
on the Board website.
• Education: 75 total hours of education relevant to the field of community health.
CCHW DOMAINS
1. Community Health Concepts
2. Advocacy and Capacity Building
3. Care Coordination
4. Health Literacy and Education
5. Safety and Self-Care
6. Cultural Competency
7. Communication and Interpersonal Skills
8. Ethical Responsibilities and Professionalism
FEE
The application fee may be paid by check, money order or with VISA, MasterCard, Discover or American
Express. One-half of the application fee is refundable if application is denied. If an employer or
organization is paying the application fee, they must include the applicants name with the payment.
Failure to include the applicants name will result in delay in approval of the application.
• Application Fee: $50 (fee must accompany application and materials)
PCB CCHW Legacy Application | www.pacertboard.org | info@pacertboard.org | Revised September 2020
6
PCB APPLICATION FOR CCHW - LEGACY
Form can be completed and saved. You may then print the appropriate pages to submit to PCB.
TYPE OR PRINT LEGIBLY
Date:
□ 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:
Email:
Cell Phone:
PRINT LEGIBLY: EMAIL IS OUR PRIMARY WAY OF COMMUNICATING WITH YOU.
If you are submitting education from a college/university for all or part of the 75-hour education requirement, official
transcripts must be submitted directly to PCB via e-transcripts or mail. It is suggested you request these three (3)
weeks prior to submitting your application.
College/University:
Name on Transcript:
Date Transcript Requested:
Delivery Method:
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
□
N
ative Hawaiian or Other Pacific Islander □ Not specified: ______________________
Employment plans for the next two years: □ Increase Hours □ Decrease Hours □ No Change □ Seek Advancement
□
R
etire □ Move to a different career □ Unknown
PAYMENT INFORMATION
FEE OF $50 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
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 CCHW Legacy Application | www.pacertboard.org | info@pacertboard.org | Revised September 2020
7
CCHW APPLICATION: EXPERIENCE & SUPERVISION INFORMATION
CURRENT VOLUNTEER/EMPLOYMENT INFORMATION
Organization Name:
How many hours do you volunteer/work per week? ______________________________________________________
Do you need to document previous volunteer/employment to fulfill the experience requirement?
□ Yes □ No
If yes, a letter (on company letterhead) from previous employer(s) verifying your duties and dates employed must be
included with your application.
DO NOT SUBMIT A RESUME WITH YOUR APPLICATION. IT WILL NOT BE REVIEWED AND IT DOES NOT FULFILL THE
DOCUMENTATION REQUIREMENT FOR EXPERIENCE.
CURRENT SUPERVISOR INFORMATION
Immediate Supervisor Name:
Email:
Phone:
Do you have more than one supervisor or need to document supervision from a previous employer?
□ Yes □ No
If yes, provide copies of the CCHW Application: Supervision Documentation Form (page 9) to all supervisors. Multiple
supervision forms can be submitted with your application.
Organization City:
Zip:
Applicant Position/Title:
Hire Date in Current Position:
Supervisor Position/Title:
Average Number of Hours of Supervision Received Per Week:
PCB CCHW Legacy Application | www.pacertboard.org | info@pacertboard.org | Revised September 2020
8
CCHW APPLICATION: SUPERVISION DOCUMENTATION FORM
Form to be completed by Applicant’s current and/or previous supervisor(s).
This form is not intended to document all experience or supervision hours of the applicant, rather the minimum hours
required for the certification. Please note: the standard hours accepted for supervision is two (2) hours per week. If you
document more than that for the applicant (your supervisee) you will need to provide documentation to the Board for
the hours to be accepted. This will delay the approval of your supervisee’s application.
Supervision is a formal or informal process that is evaluative, and supportive. It can be provided by more than one
person, it ensures quality of services, and extends over time. Supervision includes observation, mentoring, coaching,
evaluating, inspiring, and creating an atmosphere that promotes self-motivation, learning, and professional
development. In all aspects of the supervision process, ethical and diversity issues must be in the forefront.
Applicant Name:
SUPERVISOR INFORMATION
Name:
Email:
Phone:
Employer Name:
SUPERVISION DOCUMENTATION
Supervision was provided in the following Domains (check all that apply):
DOMAIN:
NUMBER OF HOURS:
□ Community Health Concepts
□ Advocacy & Capacity Building
□ Care Coordination
□ Health Literacy & Education
□
Safety & Self-Care
□ Cultural Competency
□
Communication & Interpersonal Skills
□ Ethical Responsibilities & Professionalism
Supervisor Attestation: I attest that the above-named applicant is providing providing services that are specific to the
community health worker domains and is supervised. Current supervisors: I have provided the applicant with their job
description, reviewed it with them, signed and dated it. Previous supervisors (if applicable): I have provided the
applicant with a letter (on company letterhead) listing and verifying their duties and dates employed.
______________________________________________________ _______________________________________
Supervisor Signature Date
Position/Title:
Licenses, Certifications and/or Degrees:
Employer City:
Zip:
TOTAL NUMBER OF HOURS OF SUPERVISION:
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PCB CCHW Legacy Application | www.pacertboard.org | info@pacertboard.org | Revised September 2020
9
CCHW APPLICATION 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 credential. 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 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.
INITIAL EACH STATEMENT
I have read and understood the 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 prior to
the examination, or after an unsuccessful attempt at the examination 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
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