Fillable Provisional Certification Extension Policy and Application for Provisionally

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Provisional Certification Extension Policy and Application for Provisionally

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Florida Certification Board
Provisional Certification Extension Policy and Application
for Provisionally Certified Peers and Behavioral Health Case Managers
Effective Date: December 1, 2018
Purpose: Provisional certification is valid for a 12-month period; starting on the date the provisional
credential was awarded by FCB. Within the 12-month period, provisionally certified individuals are
supposed to complete additional requirements, apply for and hold full certification. Individuals able to
demonstrate extenuating circumstances may apply for a one-time extension to the 12-month timeframe
in order to complete full certification requirements.
Policy:
A. Provisional certification extensions may be granted to individuals who were not able to earn full
certification within required timeframes for the following reasons:
a. Extended absence from work for maternity/paternity leave, Family and Medical Leave Act
(FMLA), or other extended illness. The extension will be equal to the amount of time the
employee was on approved leave.
b. Part-time staff. The extension will be granted for 6 months.
c. Other circumstance. The applicant must submit a written Extension Request Memo (see last
page of this document) packet for review and action by the FCB’s Director of Certification. The
length of the extension will vary based on circumstances, not to exceed 6 months.
B. Eligible individuals may apply for a one-time provisional certification extension by meeting the
following conditions:
a. The individual’s immediate supervisor or designee must complete and submit the Provisional
Certification Extension Application, including supporting documentation, a minimum of three (3)
weeks prior to the provisional certification expiration date.
• The FCB will not accept provisional extension applications from the provisionally certified
individual. The application must be mailed, faxed, or scanned/emailed to the FCB by the
individual’s immediate supervisor or designee.
• Individuals are NOT eligible to apply for an extension after the provisional certification has
expired.
b. The individual must agree to complete requirements and apply for full certification at least two
(2) weeks before the extension period ends.
c. The individual must pay a $75 extension fee.
C. When granted, the extension start date begins on the Provisional Certification expiration date.
D. Failure to earn full certification by the extension expiration date will result in the credential being
placed on inactive status and the individual is no longer qualified to perform duties requiring active
certification.
E. An inactive provisional certification may not be reinstated. Individuals failing to earn full
certification by the end of the extension period must start the certification process as a new
applicant, meeting all standards in place at the time of re-application, including all mandatory forms,
test requirements, and fee payment.
F. Extension requests will be reviewed for action within 10 working days of receipt.
a. When FCB grants an extension, the applicant will receive an email verifying the extension, including
directions on how to pay the fee online. Within 48 business hours of fee payment, the extension
will be processed in FCB’s database to reflect the new expiration date: you can print a wallet card
from your online account and/or the search results from the FCB webpage both serve as official
verification of the expiration date.
b. When FCB denies an extension, the applicant will receive an email indicating the denial and restating
the (1) current expiration date and (2) consequences for failure to earn certification within required
timeframes.
Extension Eligibility Table:
Eligibility
Definition
Length of Extension
Maternity or
Paternity Leave
The amount of time a new mother or
father takes off after the birth of a child.
Equal to length of approved
leave.
FMLA Any leave taken under the Family Medical
Leave Act.
Equal to length of approved
leave.
Extended Illness Leave due to illness or injury that has
exhausted all available sick leave and
results in continued absence due to the
illness or injury.
Equal to the length of approved
leave, not to exceed 6 months.
Part-time Staff Provisionally certified staff who work 30
hours or less on a regular basis.
6 month extension.
Other Any reason not identified herein that
causes the individual to be unable to earn
full certification within the 12-month
provisional certification period.
Varies, not to exceed 6 months.
Supporting Documentation: Extension requests must include verifiable, official documentation supporting
the extension request. The exact document(s) will vary based on the employer and the circumstances
surrounding the absence.
Eligibility
Supporting Documentation
Maternity or
Paternity Leave
Copy of the official notice granting leave. Must include start and end dates.
FMLA
Copy of the official notice granting leave. Must include start and end dates.
Extended Illness
Copy of the official notice granting leave. Must include start and end dates.
Part-time Staff
Letter on agency letterhead verifying part-time employment status.
Other Complete the Extension Request Memo and attach relevant supporting
documentation. The template is found on the last page of this policy.
Florida Certification Board
Provisional Certification Extension Policy and Application
for Provisionally Certified Peers and Behavioral Health Case Managers
Effective Date: January 1, 2019
This application must be completed in its entirety. All statements made on this application are subject to verification.
Last Name
First Name
Employer
Work Phone
Email
Provisional Certification Number
Provisional Certification Expiration Date
Section 3: Eligibility
Please indicate the reason you are requesting an extension. Attach a copy of official documentation supporting your
request to this application.
Maternity/Paternity Leave
FMLA
Extended Illness
Part-time Staff
Other
Section 4: Circumstances Surrounding the Extension Request
Please explain, in detail, the circumstances surrounding your need for an extension to complete certification
requirements and how you plan on completing requirements if the extension is granted. Attach supporting
documents to this application.
Attach additional pages, if necessary.
Florida Certification Board
Provisional Certification Extension Policy and Application
for Provisionally Certified Peers and Behavioral Health Case Managers
Effective Date: January 1, 2019
Last Name
First Name
Employer
Work Phone
Email
I acknowledge that the individual seeking a provisional extension is eligible for the extension under FCB policy and
understand that all additional certification requirements must be met and the upgrade application must be submitted
at least two (2) weeks before the new expiration date.
Signature
Date
Section 6: Acknowledgement of Provisional Certification Extension Policy
By affixing my signature below, I acknowledge that I understand the following requirements regarding provisional
certification and full certification. Specifically, I understand that (1) the provisional certification extension is valid for
the amount of time specified by the FCB and (2) full certification requires individuals to meet specified on-the-job
supervision and related work experience requirements at least two weeks before the new provisional certification
date.
I further acknowledge that I understand that I am applying for a one-time provisional certification extension. If
granted, I understand that I must complete all additional requirements and the upgrade application must be
submitted at least two (2) weeks before the new expiration date.
Signature
Date
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Provisional Certification Extension Policy and Application for Provisionally

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Completed 11 February 2022

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