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NBHA Certification BoardCertified Prevention Specialist ApplicationLegal Name of Applicant:Home address:City:State/Zip Code:Home phone:Email address:High School attendedName on diploma/GEDHave you ever received any disciplinary action from another certification or licensing authority? □ Yes □ No If yes, provide full details on a separate sheet.Have you ever been convicted of a felony violation in any state or federal law? □ Yes □ NoIf yes, please explain in full on a separate sheetI) Previous relevant experience (2,000 hours within the past seven years)Please complete the following tables outlining 2,000 hours of paid or volunteer prevention experience. Each entry must be signed and dated by the supervisor for that position. Please use additional sheets if needed.Employer:Address:Phone:City:State/Zip Code:Job Title:Dates employed:Hours per week:Total Hours:Duties performed:Immediate Supervisor and/or Authorized Representative of the Agency:Supervisor email address:Supervisor phone number:Supervisor Signature: _____________________________________________________ ____________________(Name) (Date)Employer:Address:Phone:City:State/Zip Code:Job Title:Dates employed:Hours per week:Total Hours:Duties performed:Immediate Supervisor and/or Authorized Representative of the Agency:Supervisor email address:Supervisor phone number:Supervisor Signature: _____________________________________________________ ____________________(Name) (Date)Employer:Address:Phone:City:State/Zip Code:Job Title:Dates employed:Hours per week:Total Hours:Duties performed:Immediate Supervisor and/or Authorized Representative of the Agency:Supervisor email address:Supervisor phone number:Supervisor Signature: _____________________________________________________ ____________________(Name) (Date)Employer:Address:Phone:City:State/Zip Code:Job Title:Dates employed:Hours per week:Total Hours:Duties performed:Immediate Supervisor and/or Authorized Representative of the Agency:Supervisor email address:Supervisor phone number:Supervisor Signature: _____________________________________________________ ____________________(Name) (Date)II) Prevention Education and Training (120 hours specific to the Certified Prevention Specialist Domains within the past five years, of which 24 hours must be Alcohol, Tobacco and Other Drug (ATOD) specific, with six hours of training in prevention ethics completed within in the past two years)Please complete the following charts detailing your hours of prevention education and training. Add additional trainings if necessary to demonstrate completion of the 120-hour requirementPlease scan and submit as documentation for the above requirements: High School Diploma or GED, relevant transcripts, training certificates, professional conference agendas, etc.TOTAL HOURS OF PREVENTION SPECIALIST EDUCATION AND TRAINING COMPLETEDTOWARDS CERTIFICATION REQUIREMENTSIC&RC Certified Prevention Specialist DomainHours Required:Hours Completed:Domain I: Planning and Evaluation 90Domain II: Prevention Education and Service DeliveryDomain III: Communication Domain IV: Community OrganizationDomain V: Public Policy and Environmental Change Domain VI: Professional Growth and Responsibility ATOD specific training 24Prevention Ethics specific training 6Total Prevention Training Hours 120TRAINING 1Title and date(s) completed: IC&RC Certified Prevention Specialist DomainHours:Domain I: Planning and Evaluation Domain II: Prevention Education and Service DeliveryDomain III: Communication Domain IV: Community OrganizationDomain V: Public Policy and Environmental Change Domain VI: Professional Growth and Responsibility ATOD specific training Prevention Ethics specific training Total Prevention Training Hours for this Course/TrainingTRAINING 2Title and date(s) completed: IC&RC Certified Prevention Specialist DomainHours:Domain I: Planning and Evaluation Domain II: Prevention Education and Service DeliveryDomain III: Communication Domain IV: Community OrganizationDomain V: Public Policy and Environmental Change Domain VI: Professional Growth and Responsibility ATOD specific training Prevention Ethics specific training Total Prevention Training Hours for this Course/TrainingTRAINING 3Title and date(s) completed: IC&RC Certified Prevention Specialist DomainHours:Domain I: Planning and Evaluation Domain II: Prevention Education and Service DeliveryDomain III: Communication Domain IV: Community OrganizationDomain V: Public Policy and Environmental Change Domain VI: Professional Growth and Responsibility ATOD specific training Prevention Ethics specific training Total Prevention Training Hours for this Course/TrainingTRAINING 4Title and date(s) completed: IC&RC Certified Prevention Specialist DomainHours:Domain I: Planning and Evaluation Domain II: Prevention Education and Service DeliveryDomain III: Communication Domain IV: Community OrganizationDomain V: Public Policy and Environmental Change Domain VI: Professional Growth and Responsibility ATOD specific training Prevention Ethics specific training Total Prevention Training Hours for this Course/TrainingTRAINING 5IC&RC Certified Prevention Specialist DomainHours:Domain I: Planning and Evaluation Domain II: Prevention Education and Service DeliveryDomain III: Communication Domain IV: Community OrganizationDomain V: Public Policy and Environmental Change Domain VI: Professional Growth and Responsibility ATOD specific training Prevention Ethics specific training Total Prevention Training Hours for this Course/TrainingTRAINING 6Title and date(s) completed: IC&RC Certified Prevention Specialist DomainHours:Domain I: Planning and Evaluation Domain II: Prevention Education and Service DeliveryDomain III: Communication Domain IV: Community OrganizationDomain V: Public Policy and Environmental Change Domain VI: Professional Growth and Responsibility ATOD specific training Prevention Ethics specific training Total Prevention Training Hours for this Course/TrainingTRAINING 7Title and date(s) completed: IC&RC Certified Prevention Specialist DomainHours:Domain I: Planning and Evaluation Domain II: Prevention Education and Service DeliveryDomain III: Communication Domain IV: Community OrganizationDomain V: Public Policy and Environmental Change Domain VI: Professional Growth and Responsibility ATOD specific training Prevention Ethics specific training Total Prevention Training Hours for this Course/TrainingTRAINING 8Title and date(s) completed: IC&RC Certified Prevention Specialist DomainHours:Domain I: Planning and Evaluation Domain II: Prevention Education and Service DeliveryDomain III: Communication Domain IV: Community OrganizationDomain V: Public Policy and Environmental Change Domain VI: Professional Growth and Responsibility ATOD specific training Prevention Ethics specific training Total Prevention Training Hours for this Course/TrainingTRAINING 9Title and date(s) completed: IC&RC Certified Prevention Specialist DomainHours:Domain I: Planning and Evaluation Domain II: Prevention Education and Service DeliveryDomain III: Communication Domain IV: Community OrganizationDomain V: Public Policy and Environmental Change Domain VI: Professional Growth and Responsibility ATOD specific training Prevention Ethics specific training Total Prevention Training Hours for this Course/TrainingTRAINING 10Title and date(s) completed: IC&RC Certified Prevention Specialist DomainHours:Domain I: Planning and Evaluation Domain II: Prevention Education and Service DeliveryDomain III: Communication Domain IV: Community OrganizationDomain V: Public Policy and Environmental Change Domain VI: Professional Growth and Responsibility ATOD specific training Prevention Ethics specific training Total Prevention Training Hours for this Course/TrainingIII) Supervised Experience in the Domains (120 hours, within the past five years, with ten hours in each domain) Please complete the NBHA CB Prevention Specialist Domains Self-Assessment and share with the supervisor(s) who shall attest below to the completion of the candidate’s requirement for certification of 120 hours of supervised experience specific to the domains, with a minimum of ten hours in each domain.Prevention Specialist Domains(120 hours required)Planning & Evaluation (minimum of 10 hours)Prevention Education & Service Delivery (minimum of 10 hours)Communication (minimum of 10 hours)Community Organization (minimum of 10 hours)Public Policy & Environmental Change (minimum of 10 hours)Professional Growth & Responsibility (minimum of 10 hours)Supervised Experience in the Certified Prevention Specialist (CPS) DomainsTotal: 120 hours of supervised experience specific to the domains, with a minimum of ten hours in each domain.CPS DomainHours required:Hours completed:Planning & Evaluationminimum of 10 hoursPrevention Education & Service Deliveryminimum of 10 hoursCommunicationminimum of 10 hoursCommunity Organizationminimum of 10 hoursPublic Policy & Environmental Changeminimum of 10 hoursProfessional Growth & Responsibilityminimum of 10 hoursTotal number of supervised hours in the Certified Prevention Specialist Domains:minimum of 120 hours Verification of Supervised Hours in the CPS DomainsUsing the NBHA CB Prevention Specialist Domains Self-Assessment as a guide, I hereby attest that the applicant is working in a position where a minimum of 50% of his/her time is spent providing prevention activities/services OR that the applicant is working in a position where a minimum of 50% of his/her time is spent providing supervision of prevention activities/services. I also attest that the applicant has received at least 120 hours of on-the-job supervision providing prevention activities/services with a minimum of 10 hours in each domain.Supervisor Name: Title:Employer:Email address:Phone number:Supervisor Signature: _____________________________________________________ ____________________(Name) (Date)IV) Demographics Questions 1 through 5 are optional. We are collecting the following data for statistical and informational purposes only. What is your highest level of Educational Attainment?High school (grades 9-12, no degree)High school graduate (or equivalent)Some college (1-4 years, no degree)Associate’s degree (including occupational or academic degrees)Bachelor’s degree (BA, BS, AB, etc.)Master’s degree (MA, MS, MENG, MSW, etc.)Professional school degree (MD, DDC, JD, etc.)Doctorate degree (PhD, EdD, etc.)Age in years: ______________Gender: MaleFemaleOther Race (check all that apply): American Indian or Alaska Native Black or African American Asian Native Hawaiian or Pacific Islander Latino Hispanic CaucasianOtherWhich of the following are part of your motivation for applying for prevention specialist certification? Check all that apply.Career advancementCareer or job change Employment requirementIncrease in hoursIncrease in payPromotionOther: ___________________Please share in writing your reasons for pursuing prevention specialist certification at this time:V) NBHA Certified Prevention Specialist Application Acknowledgements (REQUIRED)This page must be completed and notarized and submitted with the application. Please initial each statement below:____ I have read, and understood the NBHA CB Requirements for Certification - Reciprocal. ____ I have read, and understood, and signed the NBHA Code of Ethics for Prevention Specialists____ I have read, and understood the NBHA CB CPS Domains Self-Assessment.____ I either live or work in Nevada at least 50% of the time.____ I understand that one-half of fee is refundable if application is denied or cancelled prior to the exam – no refund if application is denied or cancelled after exam.____ 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 hereby request that NBHA CB grant the certification to me based on the following assurances and documentation:____ I subscribe to and commit myself to professional conduct in keeping with the NBHA Code of Ethics for Prevention Specialists;____ I hereby 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 certification. Falsification of any records or documents in my application 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 NBHA CB to officers, members, and staff of the aforementioned Board;____ I consent to authorize NBHA CB to gather information from third parties regarding continuing education and employment and understand that such communication shall be treated as confidential;____ Allegations of ethical misconduct reported to NBHA CB before, during, or after application for certification is made will be investigated by NBHA CB and could result in the nullification of the application or denial or revocation of certification.Applicant Signature: ____________________________________________________________Printed name: _________________________________________________________________Date: _________________On this the _______ day of ___________________, 20_______, by me _____________________________________a notary public, the undersigned officer, personally appeared: ______________________________________________,known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument and acknowledged that she/he executed the same for the purposes therein contained. In witness whereof, I hereby set my hand and official seal. Sworn and subscribed before me this _______ day of _________________________, 20_____._______________________________________________ SEAL:Notary PublicMail completed application to:Nevada Behavioral Health Association (NBHA) P.O. Box 14220Reno, NV 89507 ................
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