Fillable PCB CDCORP Application 19 (Pennsylvania Certification Board)

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PCB CDCORP Application 19 (Pennsylvania Certification Board)

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The PCB CDCORP Application 19 (Pennsylvania Certification Board) form is 5 pages long and contains:

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  • 27 check-boxes
  • 45 other fields

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File type: PDF

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PCB CDCORP Application | Revised October 2019
298 S. Progress Avenue, Harrisburg, PA 17109
Phone: 717-540-4455 Fax: 717-540-4458
www.pacertboard.org info@pacertboard.org
CDCORP APPLICATION
Certified Disaster Crisis Outreach & Referral Professional
PCB CDCORP Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
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 & Fee
• Page 4
Experience & DCORT Team Information
• Page 4
Trainings
• Copies of trainings
Acknowledgement & Release
• Page 5, notarized
ID Photo
• JPEG of ID photo from County or Employer
Disciplinary actions?
• Include letter of explanation with application.
Convicted of a felony?
• Include letter of explanation with application.
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.
APPLICATION INFORMATION
APPEAL PROCESS
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.
PCB CDCORP Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
3
CERTIFICATION TIME PERIOD
Certification encompasses five (5) calendar years beginning on the date the application was 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. Applicants will also be issued an ID card.
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.
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 five years. Professionals should review the
Recertification Application for credential specific requirements listed on the Board website well in advance
of their expiration date.
SERVPA
If you would consider volunteering for emergency disaster response efforts, SERVPA is your secure,
confidential volunteer registry site. Registering through SERVPA simply tells them that you are open to the
idea of volunteering in case of an emergency. You can sign up at www.serv.pa.gov
.
CDCORP REQUIREMENTS
Prior to submitting your application, applicants must have all requirements completed and documented.
EDUCATION
Specific education is required for CDCORP. Trainings can be done in person or online. Out of state trainings
are acceptable.
• National Incident Management Systems (NIMS) or Incident Command System (ICS) 100/700
• Disaster Crisis Outreach and Referral Team training (DCORT)
• Psychological First Aid (PFA)
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: $60 (fee must accompany application and materials)
PCB CDCORP Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
4
PCB APPLICATION FOR CDCORP
Form can be completed and saved. You may then print the appropriate pages to submit to PCB.
TYPE OR PRINT LEGIBLY
Date:
DOB:
□ 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.
Employer:
Position/Title:
DCORT Team Leader:
Email:
Languages spoken:
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: ______________________
Clearances (check all that apply): □ Act 13 □ Act 33 □ Act 34/114 □ Criminal Background Check
□ Not specified: ______________________
Highest level of education: □ High school diploma/GED □ Associates □ Bachelors □ Masters □ Doctorate
PAYMENT INFORMATION
FEE OF $60 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): ________________________________________________________________
DCORT Team County:
Sec. Code:
Exp. Date:
Name on Card:
Number:
-
-
-
Billing address:
(If different than Home Address)
PCB CDCORP Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
5
CDCORP 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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PCB CDCORP Application 19 (Pennsylvania Certification Board)

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Completed 3 June 2021

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