Fillable PCB Prevention CPS 2021 (Pennsylvania Certification Board)

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PCB Prevention CPS 2021 (Pennsylvania Certification Board)

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PCB CPS 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. An application is considered approved when applicant receives an email from the testing company to
register for the examination.
5. Follow all instructions to register for the examination provided in the email.
6. If you have not heard from PCB regarding your application or received an email from the testing
company to register for the examination after 10 business days, email info@pacertboard.org
.
7. Once you pass the examination, you are certified.
8. A certificate will be mailed to you within 10 business days.
CPS APPLICATION
Certified Prevention Specialist
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
2
CERTIFIED PREVENTION 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 bachelor’s degree.
It is recommended you obtain documentation approximately three weeks prior to sending in your application.
Documentation of bachelor’s degree may be mailed to PCB or emailed to info@pacertboard.org
by the
educational institution prior to application.
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.
PREVENTION WORK EXPERIENCE
REQUIRED: Two (2) years of full time or 4000 hours of part-time work experience as an
alcohol, tobacco, and drug use prevention specialist.
Qualifying work experience is based on a professional who has demonstrated competency related to alcohol,
tobacco, and drug use prevention, and who provides services that help individuals, families, and communities to
develop the capacities needed to achieve behavioral health and wellness. Prevention specialists deliver
evidence-based prevention programming in a wide range of settings including schools, workplaces, health care
centers, behavioral health programs, community-based organizations, and prevention coalitions. No other work
experience in the drug and alcohol field can be used for prevention certification other than what is stated above.
Qualifying work experience can be from multiple employers to accumulate the required years/hours.
If the applicant’s work experience requirement is not fulfilled from their current employer, they must include
documentation from previous employer(s) verifying their title, duties and dates employed with their
application. DO NOT submit a resume as proof of previous work experience. Applicant must contact previous
employers and request detailed documentation of their employment from them.
The applicant must be currently employed as a prevention specialist at the time of application. All work
experience must have occurred within the last seven (7) years. Volunteer work is not acceptable.
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
3
CURRENT JOB DESCRIPTION
REQUIRED: Copy of current prevention specialist job description, obtained from current
employer, and which must be signed by both the applicant and their immediate supervisor.
All applicants must include a copy of their current prevention specialist job description. This document is
provided by your employer and must be signed and dated by the applicant and their immediate supervisor.
Job descriptions determine and verify eligible current work experience. Job description must clearly delineate
prevention work as a primary function of the position.
If you have held different prevention positions with your current employer, please provide all relevant job
descriptions with the application. For instance, if you started as a prevention assistant, then you were promoted
to a prevention specialist, include both job descriptions.
In lieu of job description(s), employer may provide an official position description on agency letterhead. This
required documentation must include the applicants’ dates of employment (to/from) employment status (full-
time or part-time), title of position, a detailed description of the duties and responsibilities for the position, and
the average number of hours per week the applicant worked.
ON-THE-JOB SUPERVISION
REQUIRED: 120 hours of on-the-job supervision of qualifying work experience with a
minimum of 10 hours of supervision in each prevention domain.
Supervision is a formal or informal process that is administrative, evaluative, and supportive. It ensures quality
of prevention 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.
PCB has no requirements for who provides supervision. The person providing supervision is at the discretion of
the agency.
Supervision can be provided in an individual, one-on-one setting and/or observation of skills or group
supervision setting.
Supervision can be provided by more than one supervisor. In this case, provide a copy of page 10 of this
application to all the supervisors documenting supervision on your behalf.
EDUCATION/TRAINING
REQUIRED: 120 hours of prevention relevant education/training of which 24 hours must be
specific to alcohol, tobacco, and other drugs and 6 hours in prevention ethics.
Education is defined as formal, structured instruction in the form of workshops, trainings, seminars, in-services,
college/university credit courses, and online education.
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
4
There is no limit to the amount of online education that may be submitted.
Most three-credit college/university courses count as 45 hours. One training CE/CEU counts as one hour.
Out of state education is acceptable.
All education/training must be documented. College courses are documented with an official college transcript.
Trainings are documented with copies of training certificates.
Training certificates must have the applicant’s name, title of training, date(s) of training, the number of hours
being awarded, and the name of training organization. Training certificates submitted without this required
information on them will not be accepted.
If a training title on a certificate of attendance does not clearly indicate the education content, attach a copy of
the training description.
Training registration forms and/or training sign-in sheets are not acceptable forms of documentation.
Training must be non-repetitive meaning the same training cannot be claimed more than one time even if the
training is taken on different dates from different providers.
Official employer training tracking system/learning management system reports may be acceptable forms of
documentation for education/training provided that the report contains the name of the employee/applicant,
titles of each training, dates of each training, the number of hours of each training, and is signed by the
applicant’s supervisor.
There is no time limit on when the education/training was received.
EXAMINATION
REQUIRED: Once application is approved, applicant must pass the IC&RC Examination for
Prevention Specialists (PS examination).
Examination information provided on page 6 and on IC&RC’s website: www.internationalcredentialing.org.
CERTIFICATION FEE
REQUIRED: $375.00
(fee includes examination and 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 7 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.
One-half of the fee is refundable if application is denied or cancelled prior to the examination. No refund will be
issued if application is denied or cancelled after examination.
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
5
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 or register you for the examination without an email address. Please print legibly.
Applicants must either live or work in PA at the time of application.
This certification is an international, reciprocal credential recognized and transferrable to many other states and
countries.
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 prior to taking
the examination or after an unsuccessful attempt at the examination will incur a $50 application change/review
fee.
CERTIFICATION TIME PERIOD
Certification encompasses two calendar years beginning on the date the applicant passes the examination. 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 CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
6
EXAMINATION INFORMATION
TYPE OF EXAMINATION
The successful completion of an IC&RC examination is required. The examination is computer based, 150
multiple-choice questions, and offered at approved testing sites statewide. Candidates choose the day, time,
and site for their examination. Once an application is approved, candidates will receive an email from the
testing company with instructions for scheduling their examination.
TIME PERMITTED
Three hours are permitted to complete the examination.
EXAMINATION CONTENT
The examination is developed from the IC&RC Job Analysis which identifies domains and tasks for competent
practice. Domains for the examination are: Planning & Evaluation; Prevention Education & Service Delivery;
Communication; Community Organization; Public Policy & Environmental Change; Professional Growth &
Responsibility.
CANDIDATE GUIDE
The domains, including the task statements per domain, sample examination questions, and a list of references
from the IC&RC Job Analysis are included in the Candidate Guide. Candidate Guides are available from the PCB
website.
STUDY MATERIAL
Professional study guides and practice exams have been published for the examination. This information can be
found on the IC&RC’s website at: www.internationalcredentialing.org
.
SPECIAL SITUATIONS AND ACCOMMODATIONS
Individuals with disabilities and/or religious obligations that require modifications in examination administration
may request specific procedure changes in writing with official documentation to PCB no fewer than 60 days
prior to their examination date. Contact PCB on what constitutes official documentation. PCB will coordinate
appropriate modifications to the examination process when documentation supports the need.
CANCELLATION/RESCHEDULING POLICY
Candidates are required to arrive on time for their examination. Candidates who arrive late will not be
permitted to take the examination and will be charged a $175.00 cancellation/rescheduling fee. Candidates
who cancel or reschedule their examination less than five days prior to their scheduled date will be charged the
full examination fee. Candidates who cancel or reschedule more than five days before their scheduled date will
be charged a $25.00 cancellation/rescheduling fee.
RETESTING
Candidates who fail the examination can retest after a 90-day wait period from the date of their last
examination. Candidates will be sent instructions and fee information. Candidates have three (3) opportunities
to retake an examination. If a candidate fails the examination four (4) times, they must submit a study plan to
PCB and wait one-year from the date of the final failed examination before they will be permitted to retest
again.
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
7
CPS 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:
□ Female
□ 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 $375 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 CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
8
CPS: FORMAL EDUCATION
REQUIRED: Minimum bachelor’s degree.
I am including a sealed official transcript with my CPS application.
□ Yes □ No
I have ordered an official transcript to be sent to PCB. □ Yes □ No
College/University:
Name on Transcript:
Date Transcript Requested:
Delivery Method:
□ Mailed to PCB
□ Emailed to PCB
CPS: EDUCATION/TRAINING
REQUIRED: 120 hours of prevention relevant education/training of which 24 hours must be specific
to alcohol, tobacco, and other drugs and 6 hours in prevention ethics.
I have included copies of training certificates.
□ Yes □ No
I have included a copy of my training tracking system/learning management system report.
□ Yes □ No
My college transcript provides all or some of the relevant education.
□ Yes □ No
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
9
CPS: PREVENTION WORK EXPERIENCE & JOB DESCRIPTION
REQUIRED: Two (2) years of full-time or 4000 hours of part-time work experience as an alcohol,
tobacco, and drug use prevention specialist.
REQUIRED: Copy of current prevention specialist job description, obtained from current employer,
and which must be signed by both the applicant and their immediate supervisor.
CURRENT EMPLOYMENT INFORMATION
Employer Name:
How many hours do you work per week? _______________________________________________________________
Total hours/years worked in current position? ___________________________________________________________
I have attached my current prevention specialist job description, dated and signed by both me and my supervisor.
□ Yes □ No
Do you need to document previous employment to fulfill the experience requirement? □ Yes □ No
If yes, complete the section below AND submit a letter (on company letterhead) from previous employer(s) verifying your duties and dates employed
must be included with your application.
PREVIOUS EMPLOYMENT INFORMATION (IF APPLICABLE)
Letter (on company letterhead) from previous employer(s) verifying your title, duties & dates employed must be included with your application.
Organization Name:
How many hours did you work per week? _______________________________________________________________
Total hours/years worked in previous position? __________________________________________________________
Organization Name:
How many hours did you work per week? _______________________________________________________________
Total hours/years worked in previous position? __________________________________________________________
Employer City:
Zip:
Applicant Position/Title:
Start Date in Current Position:
Organization City:
Zip:
Applicant Position/Title:
Start Date in Position:
End Date in Position:
Organization City:
Zip:
Applicant Position/Title:
Start Date in Position:
End Date in Position:
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
10
CPS: ON-THE-JOB SUPERVISION
REQUIRED: 120 hours of on-the-job supervision of qualifying work experience with a minimum of 10
hours of supervision in each prevention domain.
Information below is to be completed by applicant’s current and/or previous supervisor(s).
This page is to document the supervision hours provided to the applicant, not their total work hours.
The total hours of supervision should be 120 hours but could be more depending on the applicants’ length of
employment or could be less if the applicant was provided supervision from a previous employer.
Applicants may copy this page and provide it to previous supervisors.
Applicant Name:
SUPERVISOR INFORMATION
Name:
Email:
Phone:
Employer Name:
SUPERVISION DOCUMENTATION
Supervision was provided to the above-named applicant in the following Domains:
DOMAIN
EXACT NUMBER OF HOURS
□ Planning & Evaluation
□ Prevention Education & Service Delivery
□
Communication
□ Community Organization
□ Public Policy & Environmental Change
□ Professional Growth & Responsibility
Supervisor Attestation:
I attest that the above-named applicant has been provided with supervision as documented above.
______________________________________________________ _______________________________________
Supervisor Signature Date
Position/Title:
Licenses, Certifications and/or Degrees:
Employer City:
Zip:
TOTAL NUMBER OF HOURS OF SUPERVISION:
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
11
CPS: 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 or cancelled prior to the
examination and no refund will be issued if application is denied or cancelled after examination.
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
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
12
CPS: 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 7
Formal Education page
• Page 8
Education
• Official college transcript
• Copies of training certificates (if applicable)
Work Experience
• Page 9
• Previous relevant employment documentation
(if needed)
Current job description
• Obtain from employer
Supervision page
• Page 10
Notarized Acknowledgement &
Release page
• Page 11
Checklist Page
• Page 12
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
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