Add, Change, or Remove Direct Service Staff for a ...
DEPARTMENT OF SOCIAL AND HEALTH SERVICESDOMESTIC VIOLENCE INTERVENTION TREATMENT (DVIT) PROGRAMAdd, Change, or Remove Direct Service Stafffor a Certified DVIT ProgramAll forms must be signed and filled out completely. Incomplete forms will not be accepted. See Washington Administrative Code (WAC) 388-60B for Domestic Violence Intervention Treatment (DVIT) Program standards.There is no fee to submit this application.Submit the completed application, and supporting documents to:Department of Social and Health Services (DSHS)Domestic Violence Intervention Treatment Program CertificationPO Box 45470Olympia, WA 98504-5470 Program InformationPROGRAM NAME FORMTEXT ?????TELEPHONE NUMBER (WITH AREA CODE) FORMTEXT ?????PHYSICAL ADDRESSCITYSTATEZIP CODE FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ?????DIRECTOR’S NAME FORMTEXT ?????TELEPHONE NUMBER (WITH AREA CODE) FORMTEXT ?????EMAIL ADDRESS FORMTEXT ?????New or Changing Direct Treatment StaffNAMESTAFF LEVEL REQUESTED (TRAINEE, STAFF OR SUPERVISOR)DSHS FORM 10-210, BACKGROUND CHECK AND DOH CREDENTIAL ATTACHED. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesRemoving Direct Treatment StaffNAMELAST DATE OF SERVICE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Required Documentation for New or Changing Direct Treatment Staff FORMCHECKBOX A statement of qualifications (DSHS form #10-210); and FORMCHECKBOX A current DOH license as a licensed or registered counselor and the results of current criminal history background checks, conducted in each state the person has lived in for the last ten years. AttestationI certify under penalty of perjury that the information provided in this application for certification is true and correct. I understand that any material misrepresentation or misstatement of fact may result in sanctions, including the denial or loss of program certification.DIRECTOR’S SIGNATUREDATE FORMTEXT ?????PRINT DIRECTOR’S NAME FORMTEXT ?????For Department of Social and Health Services Use OnlyAPPROVED BY: FORMTEXT ?????Certified from: FORMTEXT ?????to: FORMTEXT ?????DSHS STAFF SIGNATUREDATE FORMTEXT ?????PRINT STAFF NAME FORMTEXT ????? ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- sample pmi cancellation letter christ appraisal
- add or remove a service for an existing dvit certification
- add change or remove direct service staff for a
- permit contact change form
- sample program
- color control setting the display properties for you monitor
- template close contact notification letter for staff
- steps to remove the hp software
Related searches
- direct care staff job duties
- direct care staff duties
- direct care staff resume sample
- direct care staff training
- test for direct service workers
- direct care staff training curriculum
- direct care staff training course
- direct care staff training overview
- direct care staff training certificate
- direct care staff objective
- direct care staff skills
- direct care staff training test