Prevention Certification Manual New Hampshire Prevention Certification Board Certified Prevention Specialist (CPS)
New Hampshire Prevention Certification Board Prevention Certification Manual Certified Prevention Specialist (CPS) New Hampshire Prevention Certification Board 501 South Street, 2nd Floor, Bow, NH 03304 (603) 573‐3371 www.nhpreventcert.org [email protected] Prevention Certification Manual Updated: March, 2012; June, 2013; August, 2013, November, 2013 IC & RC Performance Domains Updated: April, 2013 TableofContents Forward: Prevention Certification ................................................................................................................ 1 Application Process ....................................................................................................................................... 2 Certification and Application Requirements ................................................................................................. 3 1. Experience Requirement ................................................................................................................... 3 2. Education Requirement .................................................................................................................... 5 3. Passing the IC&RC Prevention Specialist Written Examination ........................................................ 7 4. Code of Ethical Standards ................................................................................................................. 7 5. Residence .......................................................................................................................................... 7 IC&RC Prevention Performance Domains Defined ....................................................................................... 8 Educational Disciplines for CPS Credentials Defined .................................................................................. 10 Code of Ethical Standards ........................................................................................................................... 11 International Certification Reciprocity Consortium (IC&RC) ...................................................................... 14 1. Membership .................................................................................................................................... 14 2. Reciprocity ...................................................................................................................................... 14 3. IC&RC Written Examination ............................................................................................................ 14 Recertification Requirements ..................................................................................................................... 16 Expiration of Certification ........................................................................................................................... 18 Revocation of Provider Status ..................................................................................................................... 19 Appendices .................................................................................................................................................. 22 Application for CPS for Candidates with a Bachelor’s Degree or Higher .............................................. A‐1 Application for CPS for Candidates Who Do Not Hold a Bachelor’s Degree or Higher ....................... A‐15 Registration for IC&RC Exam for Certified Prevention Specialist (CPS) .............................................. A‐29 Recertification Application for Certified Prevention Specialist (CPS) ................................................. A‐30 Forward:PreventionCertification Prevention is defined as a proactive process which empowers individuals and systems to meet the challenges of life events and transitions by creating and reinforcing healthy behavior and lifestyles and by reducing risks contributing to alcohol, tobacco and other drug misuse and other related issues. Alcohol, Tobacco, and Other Drug (ATOD) Abuse Prevention Certification has been established in the State of New Hampshire to provide for consumer protection, promote public confidence, promote professional growth and development, and to provide an internationally recognized professional credential for prevention practitioners. The purpose of prevention certification is to recognize and ensure that substance abuse prevention practitioners meet competency standards established by the International Certification Reciprocity Consortium (IC&RC) and the New Hampshire Prevention Certification Board. This application manual details the requirements and procedures for becoming a Certified Prevention Specialist (CPS). Application materials are available for download at the NH Prevention Certification Board website at www.//nhpreventcert.org/certifications/. The CPS certification is a beginning‐level certification. Procurement of advanced certifications adopted by the Certification Board in the future will require candidates to possess a CPS. Those seeking certification who do not have extensive experience in the field of ATOD prevention should continue to aspire to fulfill the requirements to work towards certification. Recertification for the Prevention Specialist is required every two years. To fulfill recertification requirements, candidates must complete an additional forty (40) hours of continuing education in the area of ATOD prevention. Recertification materials are also available for download at the NH Prevention Certification Board Website at www.://nhpreventcert.org/certifications/. All experience and education required for certification is based on the six IC&RC Prevention Performance Domains: 1. 2. 3. 4. 5. 6. Planning and Evaluation Prevention Education and Service Delivery Communication Community Organization Public Policy and Environmental Change Professional Growth and Responsibility Questions about the certification process should be directed to the New Hampshire Prevention Certification Board at the address below: NH Prevention Certification Board 501 South Street, 2nd Floor Bow, NH 03304 (603) 573-3371 [email protected] Prevention Certification Manual | 1 ApplicationProcess The application process for the Certified Prevention Specialist has two primary steps: 1. Submission of a Complete Application: Experience, education, supervised practical experience, and adherence to the Code of Ethical Standards must be documented using the forms provided in the Application (available for download online at www://nhpreventcert.org/certifications/). One original application must be submitted to the NH Prevention Certification Board. The application can be submitted prior to taking the IC&RC Prevention Specialist Exam and up to six months after taking the exam. Applications may be submitted electronically; however, a hard copy of the Code of Ethics and signed application form must be submitted to the NH Prevention Certification Board with payment prior to the start of the review process. A non‐refundable $150 certification fee is required at the time of application or when scheduling the exam. The certification fee includes IC&RC reciprocity and examination fee. Applicants who do not pass the IC&RC exam on the initial attempt will be charged $80 to re‐ take the exam within 6 months of the initial exam date. If you do not submit your application within 6 months of taking and passing the exam, you will need to re‐take the exam and will be charged $150 to do so. Insufficient applications will be returned for completion and a $25 fee will be assessed for each subsequent review. 2. Successful completion of the IC&RC Prevention Specialist Exam: The IC&RC exam is offered quarterly: March, June, September, and December. Specific dates and deadlines for registration are posted on the NH Prevention Certification Board website at www.nhpreventcert.org/testing/. Regardless of when the exam is taken, your certification is not effective until your application is submitted and approved by the Peer Review Committee. Certification dates are recorded based on the completion and approval of applications and passage of the IC&RC exam. Prevention Certification Manual | 2 CertificationandApplicationRequirements Certification requirements vary depending on whether or not the candidate holds a minimum of a Bachelor’s degree. This section includes detail about the experience and educational requirements for both candidates with a Bachelor’s degree or higher, and for those who do not currently hold a Bachelor’s degree. In addition to the requirements included below, candidates who hold a Bachelor’s degree or higher must submit a transcript copy with their application. 1. ExperienceRequirement Candidates with a Bachelor’s degree or higher must have 2,000 documented hours of ATOD abuse prevention‐related experience in the IC&RC Prevention Performance Domains. Of those 2,000 documented hours, a minimum of 120 hours of supervision is required. Of the 120 supervised hours, a minimum of 10 hours is required in each of the six Prevention Performance Domains (see page 8 for domain definitions). For candidates who do not hold a Bachelor’s degree, additional hours are required as follows. Candidates without a Bachelor’s degree must have an additional 2,000 hours of documented experience, for a total of 4,000 documented hours. In addition, it is required that candidates without a Bachelor’s degree document an additional 120 supervised hours, for a total of 240 hours of supervision. Of the 240 supervised hours, a minimum of 20 hours is required in each of the six Prevention Performance Domains (see page 8 for domain definitions). Total Hours Supervised Hours (included in Total Hours) IC&RC Domains (included in Supervised Hours) Experience Requirement Without a Bachelor’s Degree Bachelor’s Degree or Higher 4,000 hours 2,000 hours 120 hours 240 hours 10 hours/domain 20 hours/domain Experience Defined/Types of Experience: Experience may be on either a paid or voluntary basis, with no more than 50% being voluntary. Experience and supervision must be gained from a position in which the primary job description includes substance abuse prevention (see page 1 for prevention definition). Calculating Hours of Experience: Hours of experience are based on actual time worked or volunteered. Hours are calculated based on start/end dates and average weekly schedule. The following equivalents will help you to calculate hours of experience: 1 year of full‐time employment/volunteering = 2,000 hours 1 month of full‐time employment/volunteering= 167 hours 1 week of full‐time employment/volunteering= 40 hours For example, if an individual worked half‐time (20 hours per week) for a full year, they would accumulate 1,000 hours of experience. Prevention Certification Manual | 3 Documenting Experience and Hours of Supervision: Total Hours: Total experience hours must be documented on the Documentation of Experience form included in the application materials. This form must be signed by a supervisor or program director. For candidates who do not hold a Bachelor’s degree, additional experience hours must be documented on the Documentation of Additional Experience form included in the application materials for candidates who do not hold a Bachelor’s degree. This form must be signed by a supervisor or program director. Supervised Hours: Supervised hours must be documented on the Documentation of Supervision form found in the application materials. Each supervisor must complete and sign a separate form. Although not required, it is highly recommended that the supervisor be a CPS. For candidates who do not hold a Bachelor’s degree, additional Supervised hours must be documented on the Additional Supervised Practical Experience form found in the application materials for candidates who do not hold a Bachelor’s degree. Each supervisor must complete and sign a separate form. Although not required, it is highly recommended that the supervisor be a CPS. Demonstration of Experience in the IC & RC Prevention Performance Domains: Demonstration of experience in each of the IC & RC Prevention Performance Domains must be made by the applicant on the Narrative form found in the application materials. Prevention Certification Manual | 4 2. EducationRequirement Candidates with a Bachelor’s degree or higher must have a total of 120 hours of documented education, with various hour requirements in the disciplines specified below (see page 10 for educational discipline definitions). For candidates who do not hold a Bachelor’s degree, additional hours are required as follows. Candidates without a Bachelor’s degree must have an additional 120 hours of documented education, for a total of 240 documented hours. Hourly requirements for the defined educational disciplines are consistent with the requirements for candidates who hold a degree; the additional 120 hours can be spread out across the defined disciplines. Education Requirement Bachelor’s Degree or Higher Without a Bachelor’s Degree 240 hours Total Hours 120 hours Hours by Discipline (included in Total Hours) ATOD 50 hours 50 hours Cultural Competency 15 hours 15 hours Prevention Practice and Theory* 43 hours 43 hours HIV/AIDS Training 6 hours 6 hours Prevention Ethics Training** 6 hours 6 hours Additional Hours Across Disciplines 0 hours 120 hours *Prevention Practice and Theory must include at least 6 hours of Suicide Prevention education and at least 6 hours of Violence Prevention education. This requirement is effective June 24, 2013 and is retroactive for applications through January 1, 2014 for those in the process of applying who were unaware of the change. After, January 1, 2014 this requirement is mandatory. **Prevention Ethics Training must have been completed within 1 year prior to application submission. Education Defined/Types of Education: Education is defined as formal, structured instruction in the form of workshops, seminars, institutes, in‐ service training, college/university credit courses, and Prevention Certification Board approved distance education. Details about the various types of approved education are included below: Courses or Continuing Education Units from an accredited college or university: In order to submit undergraduate or graduate coursework for credit towards the required hours, any Bachelor’s degree or higher level courses must have been completed within 5 years prior to application submission. For candidates who hold a bachelor’s degree or higher, no more than 40 classroom hours can be applied toward the education requirement. For candidates who do not hold a bachelor’s degree, no more than 80 classroom hours can be applied toward education requirement. IC & RC Approved: Education approved by an IC&RC member board can be applied toward the education requirement. On‐line Trainings and Webinars: CAPT on‐line trainings or other approved on‐line trainings listed on the NH Prevention Certification Board website can be applied toward the education requirement. Prevention Certification Manual | 5 State Sponsored Education: Education sponsored by State of New Hampshire Departments, such as the NH Training Institute, which is relevant to the IC&RC Prevention Educational Disciplines, can be applied toward the education requirement. Substance Abuse Coordinating Agencies Sponsored Education: Education sponsored by Substance Abuse Coordinating Agencies, such as community mental health and human service organizations, which is relevant to the IC&RC Prevention Performance Domains, can be applied toward the education requirement. At least 50% of course work for initial certification must be pre‐approved by an IC & RC Prevention Certification Board. All workshop, in service education, on‐line training, or college course certificates of completion that are not sponsored by the NH Training Institute must be submitted with a syllabus, agenda, or workshop description from the training as proof of its’ appropriateness for the discipline chosen. Calculating Hours of Education: The following equivalents will help you to calculate hours of education: 1 Credit Hour/Contact Hour = 1 CEU = 1 hour of education for certification Documenting Education: Education hours by discipline must be documented on the NH Prevention CPS Education Documentation form included in the application materials. If you do not have certificates of completion for one or more workshops, you must fill out the form titled Education Form for Undocumented Events included in the application materials. Your supervisor or program director must sign this form to verify that you have attended the listed workshops. Listing education on this form should be the exception in your documentation. Only 30% (36 hours for candidates who hold a Bachelor’s degree, 72 hours for candidates who do not hold a Bachelor’s degree) of total education can be applied with this form. PREVENTION ETHICS TRAINING MUST BE DOCUMENTED, AND MAY NOT BE LISTED ON THIS FORM. You should make every effort to locate missing verification of educational hours before using this form. This form can also be used to document in‐service trainings. Prevention Certification Manual | 6 3. PassingtheIC&RCPreventionSpecialistWrittenExamination Information about the IC&RC exam is included in the section titled IC&RC, which begins on page 14. 4. CodeofEthicalStandards A notarized signature is required acknowledging the willingness to follow the New Hampshire Prevention Certification Board Code of Ethical Standards. The Code of Ethnical Standards form is included in the application materials (a hard copy of this document must be mailed before a review of your electronically submitted application). 5. Residence Applicants must live or work at least 51% of the time in the state of New Hampshire. The NH Prevention Certification Board may certify those outside their jurisdiction ONLY if the Board in the candidate’s jurisdiction does not offer the particular credential the candidate is seeking. For example, we may certify those living in states near us who do not currently offer the CPS credential. Prevention Certification Manual | 7 IC&RCPreventionPerformanceDomainsDefined Domain 1: Planning and Evaluation Weight on Exam: 30% Associated Tasks: • Determine the level of community readiness for change. • Identify appropriate methods to gather relevant data for prevention planning. • Identify existing resources available to address the community needs. • Identify gaps in resources based on the assessment of community conditions. • Identify the target audience. • Identify factors that place persons in the target audience at greater risk for the identified problem. • Identify factors that provide protection or resilience for the target audience. • Determine priorities based on comprehensive community assessment. • Develop a prevention plan based on research and theory that addresses community needs and desired outcomes. • Select prevention strategies, programs, and best practices to meet the identified needs of the community. • Implement a strategic planning process that results in the development and implementation of a quality strategic plan. • Identify appropriate prevention program evaluation strategies. • Administer surveys/pre/posttests at work plan activities. • Conduct evaluation activities to document program fidelity. • Collect evaluation documentation for process and outcome measures. • Evaluate activities and identify opportunities to improve outcomes. • Utilize evaluation to enhance sustainability of prevention activities. • Provide applicable workgroups with prevention information and other support to meet prevention outcomes. • Incorporate cultural responsiveness into all planning and evaluation activities. • Prepare and maintain reports, records, and documents pertaining to funding sources. Domain 2: Prevention Education and Service Delivery Weight on Exam: 15% Associated Tasks: • Coordinate prevention activities. • Implement prevention education and skill development activities appropriate for the target audience. • Provide prevention education and skill development programs that contain accurate, relevant, and timely content. • Maintain program fidelity when implementing evidence‐based practices. • Serve as a resource to community members and organizations regarding prevention strategies and best practices. Domain 3: Communication Weight on Exam: 13% Associated Tasks: • Promote programs, services, activities, and maintain good public relations. Prevention Certification Manual | 8 • Participate in public awareness campaigns and projects relating to health promotion across the continuum of care. • Identify marketing techniques for prevention programs. • Apply principles of effective listening. • Apply principles of public speaking. • Employ effective facilitation skills. • Communicate effectively with various audiences. • Demonstrate interpersonal communication competency. Domain 4: Community Organization Weight on Exam: 15% Associated Tasks: • Identify the community demographics and norms. • Identify a diverse group of stakeholders to include in prevention programming activities. • Build community ownership of prevention programs by collaborating with stakeholders when planning, implementing, and evaluating prevention activities. • Offer guidance to stakeholders and community members in mobilizing for community change. • Participate in creating and sustaining community‐based coalitions. • Develop or assist in developing content and materials for meetings and other related activities. • Develop strategic alliances with other service providers within the community. • Develop collaborative agreements with other service providers within the community. • Participate in behavioral health planning and activities. Domain 5: Public Policy and Environmental Change Weight on Exam: 12% Associated Tasks: • Provide resources, trainings, and consultations that promote environmental change. • Participate in enforcement initiatives to affect environmental change. • Participate in public policy development to affect environmental change. • Use media strategies to support policy change efforts in the community. • Collaborate with various community groups to develop and strengthen effective policy. • Advocate to bring about policy and/or environmental change. Domain 6: Professional Growth and Responsibility Weight on Exam: 15% Associated Tasks: • Demonstrate knowledge of current prevention theory and practice. • Adhere to all legal, professional, and ethical principles. • Demonstrate cultural responsiveness as a prevention professional. • Demonstrate self‐care consistent with prevention messages. • Recognize importance of participation in professional associations locally, statewide, and nationally. • Demonstrate responsible and ethical use of public and private funds. • Advocate for health promotion across the life span. • Advocate for healthy and safe communities. • Demonstrate knowledge of current issues of addiction. • Demonstrate knowledge of current issues of mental, emotional, and behavioral health. Prevention Certification Manual | 9 EducationalDisciplinesforCPSCredentialsDefined Educational disciplines are defined as follows. Alcohol, Tobacco, and Other Drug (ATOD): The history, uses, trends and pharmacology of stimulants, depressants, psychotherapeutic drugs, alcohol, tobacco and various other substances as well as the psychological, biological and social aspects of substance abuse. Appropriate intervention for prevention and treating substance abuse in special populations is also acceptable. Cultural Competency: May focus on the aspects of culture that include not just the recognition of diversity among racial and ethnic groups and language differences, but also recognizing the importance of gender, age, socio‐economic, sexual orientation, religious, geographic and political difference across the state. Prevention Practice and Theory: Can include, but is not limited to, workshops on sustainability, planning, development, community engagement, collaboration, implementation of evidence based programs, practices and strategies, assessment, capacity building, grant writing and evaluation. Six of the required hours for initial certification must be specifically for Suicide Prevention relative to substance misuse disorders and six hours must be specifically for Violence Prevention. Violence Prevention may include sexual, domestic or bullying as long as they are for prevention specific research, strategies or interventions relative to substance misuse disorders. Ethics: Must be specific to Prevention Ethics and based on the Code of Ethical Standards for the initial certification. Recertification ethics trainings can include any ATOD related ethics workshops. HIV/AIDS: Must provide participants with basic and updated information about HIV and AIDS. This includes risk factors, modes of transmission, signs and symptoms, prevention, the relationship between HIV and AIDS, and updated information on mother‐to‐child transmission and prevention and an overview of the epidemic. Prevention Certification Manual | 10 CodeofEthicalStandards Principle 1: Non‐Discrimination 1. The Certified Prevention Specialist must not discriminate against service recipients, colleagues, or the general public based on race, religion, age, sex, national ancestry, sexual orientation, economic or handicapping conditions. 2. The Certified Prevention Specialist should broaden his or her understanding and acceptance of cultural and individual differences, in order to render services and provide information sensitive to those differences. Principle 2: Personal Responsibility 1. The Certified Prevention Specialist shall exercise competent professional judgment when dealing with service recipients, colleagues, or the general public and shall maintain their best interest at all times. 2. The Certified Prevention Specialist shall serve as a responsible role model in applying prevention concepts to public and professional relationships. Principle 3: Professional Competence 1. The Certified Prevention Specialist shall provide competent, professional service to all in keeping with the State of New Hampshire Standards. Competent professional service required: a) Thorough knowledge of ATOD abuse prevention b) Skill in presentation and education techniques c) Thoroughness and preparation reasonably necessary to assure the highest level of quality d) Service, and e) Willingness to maintain current and relevant knowledge through ongoing professional education 2. The Certified Prevention Specialist shall assess personal competence, recognize personal boundaries and limitations, and not offer services beyond his/her skill or training level. Principle 4: Professional Standards 1. The Certified Prevention Specialist (CPS) shall maintain the highest professional standards and: a) Shall not claim either directly or by implication, professional knowledge, qualifications or affiliations that the CPS does not possess. b) Shall not lend his/her name to, or participate in, any professional and/or business relationship that may knowingly misrepresent or mislead the public in any way. c) Shall not misrepresent his/her certification to the public or make false statements regarding their qualifications to the New Hampshire Prevention Certification Board. d) Must ensure that any materials or products, with which he/she is associated in developing or promoting, whether for commercial sale or other use, are presented in a professional and factual way. e) Shall recognize the effect of substance use on professional performance and must be willing to seek appropriate treatment for oneself or to support colleague in need of treatment services. Prevention Certification Manual | 11 f) Must fairly and accurately report appropriate prevention information to service recipients, colleagues, and the general public, acknowledging and documenting sources, materials and techniques used. g) Must not misrepresent the work of others. h) Must not misrepresent one’s own prevention work for personal or professional recognition, funding, or other gain. Principle 5: Public Statements 1. The Certified Prevention Specialist must respect the limits of current knowledge in public statements concerning the effectiveness of prevention initiatives, prevention programs, prevention research, and ATOD information 2. The Certified Prevention Specialist who conducts training in prevention must indicate to the audience the requisite training/qualifications required to properly implement the material, program, or techniques presented/taught in training. Principle 6: Material Credit 1. The Certified Prevention Specialist who participates in the writing, editing, development or production of professional papers, videos/films, pamphlets, books, or any other prevention materials, must acknowledge and document any published or unpublished materials, techniques, or sources used in creating these materials. 2. The use of copyrighted materials without first receiving author approval is against the law and in violation of professional ethics. Principle 7: Recipient Welfare 1. The Certified Prevention Specialist shall maintain objectivity, integrity, and the highest professional standards in: a) Delivering prevention services b) Providing a supportive environment c) Protecting the welfare and upholding the best interest of both individual recipients and the public d) Maintaining an objective, non‐possessive relationship with those they serve and not exploiting them sexually, financially, or emotionally e) Maintaining an ability and willingness to make appropriate referrals Principle 8: Confidentiality 1. The Certified Prevention Specialist has the responsibility to be aware of and in compliance with all applicable state and federal guidelines, regulations, statutes, and agency policies, i.e. a) Notification of recipient rights b) Reporting child abuse and neglect c) Reporting misconduct by individuals or agencies d) Maintaining client confidentiality and safeguarding from disclosure confidential information acquired during service delivery Prevention Certification Manual | 12 Principle 9: Professional Integrity 1. The Certified Prevention Specialist should: a) Never knowingly make false statements to the appropriate licensing/certifying disciplinary authority b) Promptly alert colleague to potentially unethical behavior so said colleague can take corrective action c) Report violations of professional conduct by other prevention professionals to the appropriate licensing/certification disciplinary authority when there is knowledge that the said professional has violated professional standards Principle 10: Remuneration 1. The Certified Prevention Specialist must establish financial arrangements in professional practice in accordance with the professional standards that safeguard the best interests of service recipients, colleagues, and the public. 2. The Certified Prevention Specialist must not send or receive a commission or rebate or any other form of remuneration for referral of service recipients for professional services. 3. The Certified Prevention Specialist must not exploit one’s relationship with service recipients to promote personal gain or the profit of any agency or commercial enterprise of any kind. Principle 11: Societal Obligations 1. The Certified Prevention Specialist should: a) Advocate for consistent health promotion and awareness message to the general public b) Provide factual state‐of‐the‐art ATOD prevention information to the consumers of prevention services c) Advocate public policy that would help strengthen the overall health and well‐being of the community Principle 12: Professional Obligations 1. In addition to adhering to the obligations stated above, the CPS should strive to maintain and promote the integrity of certification within the State of New Hampshire, nationally and internationally, and the advancement of the ATOD prevention profession. Prevention Certification Manual | 13 InternationalCertificationReciprocityConsortium(IC&RC) 1. Membership A. New Hampshire has membership in the International Certification Reciprocity Consortium/Alcohol and Other Drug Abuse (IC&RC). The IC&RC’s membership currently exceeds 40 states, the U.S. Military, Indian Health Services, Canada, Sweden, Germany, Bermuda, and the District of Columbia. B. Membership in the IC&RC allows New Hampshire Certified Prevention Specialists to receive reciprocal certification in other IC&RC member states and countries. 2. Reciprocity A. Definition a) Each certifying body (including the New Hampshire Prevention Certification Board) belonging to the IC&RC agrees to use the IC&RC’s minimum standards for reciprocity‐eligible certifications. For example, if an IC&RC member board offers a reciprocity‐eligible Prevention Certification, the IC&RC’s minimum standards for Prevention Certification must be used. However, every member board does not have to offer reciprocity‐eligible certification established by the IC&RC. b) Each IC&RC member certifying body agrees to accept the reciprocity‐eligible certification(s) of other members if an equivalent certification is offered. c) The IC&RC has established minimum standards for Prevention Certification. These minimum standards are for the Certified Prevention Specialist. However, not all IC&RC members have developed a reciprocity‐eligible Prevention Certification. B. Applying for Reciprocity a) Contact the New Hampshire Prevention Certification Board for an IC&RC reciprocity application for Prevention Certification. b) Before mailing the reciprocity application and fee to IC&RC, verify that the new certification board offers a reciprocity‐eligible Prevention Certification by contacting the New Hampshire Prevention Certification Board. 3. IC&RCWrittenExamination A. Examination Content a) The exam is 150 multiple‐choice questions. The major Performance Domains addressed in the exam are: Planning and Evaluation Prevention Education and Service Delivery Communication Community Organization Public Policy and Environmental Change Professional Growth and Responsibility b) The job tasks for each Performance Domain are detailed later in this section. Prevention Certification Manual | 14 B. References for the IC&RC Exam A complete list of references for studying for the IC&RC exam can be downloaded from the NH Prevention Certification Board website from the Documents page at www.nhpreventcert.org/documents/. The Substance Abuse Prevention: Intersection of Science and Practice book is also available for loan through the NH Prevention Certification Board, or can be purchased for $80. The loan fee is $15 and can be applied toward the purchase price should an applicant choose to own this resource. This resource can be borrowed by sending a check to our office for $15 with your application. It can only be requested for loan once an application has been received and must be returned the day of testing in its’ original condition. C. Examination Dates and Locations The examinations are given quarterly in March, June, September and December. Exam dates and location will be given to you at the time of application and are available for review at www://nhpreventcert.org/testing/. D. Examination Registration and Fees a) Applications may be obtained by contacting the New Hampshire Prevention Certification Board. b) The fee for the IC&RC Prevention Specialist Written Examination is included in your application cost. An additional charge of $80 will be assessed if you are re‐taking the exam after not passing on your initial attempt. c) The registration application and fee must be received at the NH Prevention Certification Board six (6) weeks in advance of the examination date. Those interested in registering to take the exam are encouraged to review the exam dates and registration deadlines, posted at www://nhpreventcert.org/testing/. d) Unfortunately, due to IC&RC rules, testing fees are non‐refundable, even in emergency situations. If there is a need to cancel after a test is ordered for your certification, you will be required to pay an $80 fee for the re‐ordering of the test for the next regularly scheduled testing date. E. Special Circumstances a) Individuals with disabilities and/or religious obligations that require modifications in test administration may request specific procedural changes through submission of a Special Accommodations form. This form can be downloaded from the NH Prevention Board website at www://nhpreventcert.org/documents/. b) The request must be submitted in writing to the New Hampshire Prevention Certification Board no fewer than 120 days prior to the scheduled test date. c) Official documentation of the disability or religious issue must be submitted with the request. The form to be used for documentation is available for download with the Special Accommodations form at www://nhpreventcert.org/documents/. Prevention Certification Manual | 15 RecertificationRequirements A. General Information 1. All prevention certifications expire in the month of issuance two years from the date of certification. All continuing education for recertification must be within that two year period. 2. Forty (40) hours* of continuing education in the Disciplines is required every two years for recertification. Six (6) hours must come from an approved Ethics Training. As noted on page 10, recertification ethics trainings can include any ATOD related ethics workshops. While not required for recertification, the NH Prevention Certification Board recommends additional HIV training on a regular basis as part of a prevention professional’s continued education. *Effective 1/1/14, six (6) hours of Suicide Prevention training becomes a requirement for a recertification within the 40 hours of required training. *Effective 1/1/14, six (6) hours of Violence Prevention training becomes a requirement for recertification within the 40 hours of required training. *In lieu of the new training requirements for Suicide and Violence prevention, applicants may present documentation of previous trainings for Suicide and Violence prevention going back to their original certification application. These cannot be undocumented hours. 3. The NH Prevention Certification Board Recertification Application should be used when applying for recertification. This form can be found on the NH Prevention Certification Board website at www.nhpreventcert.org/certifications/. 4. All workshops, in service education, on‐line training, or college course certificates of completion that are not sponsored by the NH Training Institute must be submitted with a syllabus, agenda, or workshop description from the training as proof of its’ appropriateness for the discipline chosen. 5. If you do not have certificates of completion for any workshops, you must fill out the form titled For Undocumented Training found in the application materials and have your supervisor or program director sign the bottom to verify that you have attended the listed workshops. Listing education on this form should be the exception in your documentation. Only 30% (12 hours) of total education can be applied with this form. ETHICS TRAINING MUST BE DOCUMENTED, AND MAY NOT BE LISTED ON THIS FORM. You should make every effort to locate missing verification of educational hours before using this form. This form can also be used to document in‐services. 6. A recommitment to the Code of Ethical Standards is required. Applicants are required to resubmit a signed, notarized copy of the Code of Ethical Standards form. 7. Recertification applications may be submitted electronically, however the original hard copy of the Code of Ethical Standards with payment and the signed application form must be sent to the NH Prevention Certification Board prior to the start of the review process. 8. A non‐refundable $75.00 recertification fee is required at the time of each recertification. 9. The Certified Prevention Specialist Certificates may be renewed as often as needed. Prevention Certification Manual | 16 B. Alternatives to Continuing Education Requirement for Recertification 1. Up to 30% (12 hours) of the continuing education hours for recertification may be met through teaching and/or training experience as detailed below: a) Up to twelve (12) hours spent in teaching and/or training at educational events related to the Educational Disciplines may be applied to CEU’s. b) Twelve (12) hours is the maximum allowance of hours from teaching/training that may be used every two year period. c) The numbers of contact hours applicable is equal to the number of contact hours for the educational event. Prevention Certification Manual | 17 ExpirationofCertification A. Notification 1. Certified Prevention Specialists will be notified by mail or email 60‐90 days prior to the upcoming expiration date. This is a courtesy reminder and failure to receive this reminder does not negate the responsibility to recertify in a timely manner. 2. Failure to recertify will result in the loss of the Prevention Certificate. B. Exceptions 1. Recertification can be applied for up to 180 days after the expiration date by: a) Meeting recertification requirements, b) Completing the recertification application, c) Paying the appropriate recertification fee, and d) Paying a late fee of $25.00. 2. If the Prevention Specialist is successfully recertified, the new recertification date will be the same as if the recertification had occurred in a timely manner. 3. If the application for recertification is made within 180 days after the expiration date, the following requirements must be met: a) Meeting recertification requirements, b) Completing recertification application, c) Signing and notarizing a copy of the Code of Ethical Standards, d) Paying the appropriate recertification fee of $75.00, e) Paying a late fee of $25.00, and f) Documenting the completion of 20 additional hours of continuing education in the Disciplines per year since the beginning of the last certification period. 4. If the Prevention Specialist fails to re‐apply within 180 days after the expiration date, the Prevention Specialist must go through the original certification process referenced on page 6 of this manual. These rules are strictly enforced. C. Recertification Extensions 1. The expiration date of a Prevention Certification may be extended for up to 90 days under the following conditions: a) A medical condition, documented by a physician, which has severely limited normal activities for at least 30 days within the last 180 days prior to the recertification expiration date. b) Unemployment for a period of at least 90 days within the year prior to the expiration date. c) Time off from work due to a relative’s home care needs (e.g. spouse, parent, child, grandparent, or live‐in companion) for at least 30 days within the last 180 days prior to the expiration date. 2. Application for extensions must be made in writing on or before the certification expiration date. Prevention Certification Manual | 18 RevocationofProviderStatus A. Violation of Board Provisions 1. The practice of fraud or deceit in procuring or attempting to obtain Prevention Certification under the NH Prevention Certification Board 2. Violation of the Code of Ethical Standards 3. Violating any provision of the NH Prevention Certification Board or any substantive rule adopted by this Board B. Revocation Hearing Procedure 1. Specific allegations are to be made in writing to the Chairperson of the Non‐Profit Board of Directors, who will forward all information to the Revocation Hearing Committee. The allegation received shall be recorded by the Board of Directors and shall contain the following information: a) Provider’s name b) Name of the complaining party c) Date of complaint d) Brief statement of complaint 2. The Board of Directors will appoint a three‐person Revocation Hearing Committee, consisting of certified prevention professionals. No member shall be appointed to the Revocation Hearing Committee who has a potential conflict of interest with either side. All potential conflicts of interest will be discussed prior to the appointment. 3. The Provider will be informed in writing of any Board of Directors review and will be asked to provide documentation. This may include, but not be limited to: a) Records pertaining to specific course offerings b) Records of course offerings c) Financial records pertaining to a specific course offering(s) d) Documentation of faculty and their credentials 4. The Provider has thirty (30) days to forward all requested documentation to the Board of Directors. A Revocation Hearing Committee meeting will be held within three (3) months. Failure to comply with said request will place the Provider on inactive status, and any training credits during this time will not be accepted by the NH Prevention Certification Board. 5. The Provider can appeal the Revocation Hearing Committee decision, in writing, to the Board of Directors. A final determination will be made at that time, and the Provider may be represented at the meeting. The Board of Directors will hear the appeal within three (3) months of the appeal request. C. Applicant Appeals 1. When an applicant is denied certification, questions the results of the portfolio review, questions examination results, or is subject to an action by the NH Prevention Certification Board that he or she deems unjustified, the applicant has the right to an inquiry and appeal. 2. If an applicant deems that an action taken by the NH Prevention Certification Board is unjustified, he or she is entitled to written summary from the NH Prevention Certification Board Prevention Certification Manual | 19 that explains the reasons for the action. All correspondence will be sent certified return receipt mail, with a postmark date being the date from which the thirty (30) days shall be counted. If the applicant does not agree with the Certification Board decision, he or she may request an Appeals Hearing. 3. The applicant may appeal the decision to the Non‐Profit Board of Directors within thirty (30) days of receipt of the summary, notice of denial, or any other action deemed unjustified by sending a certified letter to the Chairperson of the Board of Directors at the Board mailing address. D. Appeals Hearing Procedure 1. If a request for an Appeals Hearing is submitted to the Board of Directors within the specified timeframe, the Board of Directors will appoint a three‐person Appeals Hearing Committee, consisting of prevention certified professionals. No member shall be appointed to the Appeals Hearing Committee who has a potential conflict of interest with either side. All potential conflicts of interest will be discussed prior to the appointment. 2. Within twenty‐one (21) days after the Board of Directors receives a request for an appeal, an Appeals Hearing into the facts contained in the Certification Board’s decision shall be scheduled, and the Chairperson of the Board of Directors shall send by certified mail a notice of the Appeals Hearing to the complainant. The Appeals Hearing shall be scheduled no less than twenty‐one (21) days and no more than ninety (90) days from the date of the Appeals Hearing notice. 3. The notice of the Appeals Hearing shall advise the complainant of the following: a) The date, time, and the location of the Appeals Hearing and the identity of the Appeals Hearing Committee members. b) At the complainant’s own expense, the complainant may be represented by Counsel at the Appeals Hearing. c) The NH Prevention Certification Board’s representative shall present evidence in support of its recommendation at the Appeals Hearing. Such evidence shall be limited to the issues contained in the summary issued to the complainant prior to the appeals process. d) The complainant may present and rebut evidence and present and cross‐examine witnesses. e) The Appeals Hearing Committee shall not be bound by common law or statutory rules of evidence, and the Appeals Hearing Committee may consider all evidence having reasonable probative value. f) The Appeals Hearing Committee will base its decision upon the evidence presented at the Hearing. g) Any request by the complainant for postponement of the Appeals Hearing must be immediately served in writing to the Chairperson of the Board of Directors. The decision to grant or deny such request is discretionary with the Board of Directors. h) There shall be no contact prior to the Appeals Hearing between the complainant and any NH Prevention Certification Board members for the purpose of discussing in any way the Certification Board’s decision, or the appeal. i) The Appeals Hearing shall be closed to the public. 4. Failure of the complainant to attend the Appeals Hearing shall be deemed a waiver of the appeal. In such cases, the Appeals Hearing will be dismissed and the decision of the NH Prevention Certification Board shall take immediate effect. Prevention Certification Manual | 20 5. Within twenty‐one (21) days after the completion of the Appeals Hearing, the Appeals Hearing Committee shall prepare a written decision containing Findings of Fact and a Conclusion. The Board of Directors shall mail a copy of the decision to the complainant by certified mail. The decision of the Appeals Hearing Committee shall be deemed that of the NH Prevention Certification Board, shall be effective upon issuance or at such date as the Appeals Hearing Committee shall specify, and shall be final, without further action by the NH Prevention Certification Board. 6. At any time prior to the issuance of the Appeals Hearing Committee’s written decision, the complainant and the NH Prevention Certification Board, acting through its representative, may enter into a consent order. Such consent order shall state the nature of the complaint and the details of the agreement and shall supersede any prior decision in the case. Prevention Certification Manual | 21 Appendices Prevention Certification Manual | 22 New Hampshire Prevention Certification Board ApplicationforCertifiedPreventionSpecialist(CPS) forCandidateswithaBachelor’sDegreeorHigher Information must be typed or printed. Incomplete applications will not be considered. Section 1: Personal Information Name (as it should appear on your certificate):_______________________________________________ Address:______________________________________________________________________________ City/State/Zip:_________________________________________________________________________ Home Phone:__________________________ Cell Phone:_____________________________________ Email:_________________________________ Work Phone: __________________________________ Program/Business Name:________________________________________________________________ Program/Business Address:______________________________________________________________ City/State/Zip:________________________________________________________________________ Section 2: Signature Requirement I hereby certify that all of the information being submitted in this application is true and accurate, and that I have read, signed, and ascribed to the attached Code of Ethical Standards. _____________________________________________________ Applicant’s Signature __________________________ Date Certification fee is $150 for two years and is non‐refundable. Please see Page 2 of the Prevention Certification Manual for further information on fee structure. Please attach check or money order made payable to New Hampshire Prevention Certification Board. Alternatively, you can pay using PayPal by selecting the Application fee link at www.nhpreventcert.org/testing/. Completed application packets with payment can be mailed to: New Hampshire Prevention Certification Board, 501 South Street, 2nd Floor, Bow, NH 03304. NH Prevention Certification Board – Application for CPS (Candidates with Bachelor’s Degree) – Revised 12.9.2013 A‐1 New Hampshire Prevention Certification Board PortfolioReviewChecklist Applicant’s Name: ______________________________________________________________________ APPLICATION‐ one original and two copies Completed and Signed Documentation of Name Change (if required) EXPERIENCE Total Number of Hours Three (3) Recommendation Forms on File (forms should be sent directly to the Cert Board from the reference) Narrative completed and Attached Resume and Job description(s) Attached Not to be sent in by Applicant SUPERVISED PRACTICAL EXPERIENCE Total Number of Hours CODE OF ETHICAL STANDARDS Signed and Notarized EDUCATION Total Number of hours ATOD hours Cultural Competency hours Prevention Practice and Theory hours Suicide Prevention Violence Prevention HIV/AIDS Training hours Prevention Ethics Training hours College Transcript (or Ed Waiver Form) Attached Certification Staff Use Only Applicant TESTING AND REVIEW (exam can be taken within 6 months prior to or after submitting application) Passed IC&RC Prevention Specialist Exam This checklist should be the second document in your application packet. This checklist provides a location for you to record compliance with certification criteria, and a location for NH Prevention Certification Board staff to record the outcome for their review of the documents you have submitted. NH Prevention Certification Board – Application for CPS (Candidates with Bachelor’s Degree) – Revised 12.9.2013 A‐2 New Hampshire Prevention Certification Board DocumentationofExperience In cases where an applicant has had experience at more than one site/employer, a separate form should be filled out for each location of experience. Please note that a copy of the applicant’s resume must be attached to this form. All information must be typed or printed. Section 1: Applicant Information Name:________________________________________________________________________________ Section 2: Program Information Program Name: ________________________________________________________________________ Program Address:______________________________________________________________________ City/State/Zip:_________________________________________________________________________ Daytime Phone Number:_________________________________________________________________ Section 3: Documentation of Experience Please attach a copy of the applicant’s job description on, or attached to, program letterhead. Applicant’s Position:____________________________________________________________________ Start Date:_______________________________ End Date:_______________________________ Average Weekly Schedule (hours)*:________________________________________________________ * Experience hours are calculated based on start/end dates and average weekly schedule. Indicate the average number of direct and indirect hours per week the applicant spent in the ATOD prevention activities of planning and evaluation, education and skill development, community organization, public policy, and professional growth and responsibility. Full time ATOD Prevention Specialists may enter 40 hours. Section 4: Signature Requirement By signing below, I attest that the applicant named in Section I worked as a prevention professional at this program providing prevention services, and I endorse this candidate for certification. ________________________________________________ Signature of Supervisor or Program Director __________________________ Date Certified Prevention Specialists are required to have 2,000 hours of ATOD‐related Prevention experience. NOTE: Volunteer experience can only count for 50% of total experience (1000 hours). The Program Director or Supervisor of the program in which the experience was gained should complete this form. If the experience was in several programs, each of them should complete copies of this form. SUPERVISOR: Please complete and sign this form and return it to the applicant with a copy of the applicant’s job description, for submission with his/her Certification Application. APPLICANT: Please enter the total number of documented experience hours on the Applicant Checklist. NH Prevention Certification Board – Application for CPS (Candidates with Bachelor’s Degree) – Revised 12.9.2013 A‐3 New Hampshire Prevention Certification Board DocumentationofSupervision In cases where an applicant has had supervision by multiple supervisors (due to multiple employers/programs), each supervisor should fill out a separate form. All information must be typed or printed. Section 1: Applicant Information Name:________________________________________________________________________________ Section 2: Program Information Program Name: ________________________________________________________________________ Program Address:______________________________________________________________________ City/State/Zip:_________________________________________________________________________ Daytime Phone Number:_________________________________________________________________ Section 3: Documentation of Experience Indicate the total number of hours Supervision for each of the Prevention Performance Domains* listed: 1. Planning and Evaluation 2. Prevention Education and Service Delivery ______hours 3. Communications 3. Community Organization 4. Public Policy and Organizational Change ______hours 5. Professional Growth and Responsibility ______hours ______hours ______hours ______hours TOTAL ______hours *Please consult with the prevention certification applicant if additional information regarding the content of the Performance Domain is needed. Section 4: Signature Requirement By signing below, I attest that the applicant received supervision in the Performance Domains as listed above, and I endorse this candidate for certification. ________________________________________________ Signature of Supervisor or Program Director __________________________ Date Certified Prevention Specialists must have 120 hours of Supervision in the Prevention Performance Domains, with at least 10 hours in each of the listed Performance Domains. The person or persons supervising the applicant should complete this form or forms. SUPERVISOR: Please return the completed form to the applicant for submission with his/her application. APPLICANT: Transfer the total number of Supervised Practical Training hours to the Application Check List. NH Prevention Certification Board – Application for CPS (Candidates with Bachelor’s Degree) – Revised 12.9.2013 A‐4 New Hampshire Prevention Certification Board EducationDocumentation Please review pages 5 through 6 of the Prevention Certification Manual before completing this form. Education is defined as formal, structured instruction in the form of workshops, seminars, institutes, in‐services, college/university credit courses and Prevention Certification Board approved distance education. Further detail about the various types of allowable education is included on page 5 of the Prevention Certification Manual. Educational Disciplines are defined on page 8 of this application packet and on page 10 of the Prevention Certification Manual, specific hour requirements are detailed in the chart below. The next page can be copied to allow for more entries. ATOD Cultural Competency Prevention Practice and Theory** Ethics*** HIV/AIDS Total Training Time 50 15 43 6 6 120 6 6 6 Total for this page Total for all pages Education Discipline Title Total Hours Required (see note below)* Example: Understanding Coalition Building Theory and Practice Example: Prevention Ethics * Total training in this column must equal 120 hours for those with a Bachelor’s degree. **Prevention Practice and Theory must include 6 hours of Suicide Prevention Training and 6 hours of Violence Prevention Training *** Prevention Ethics Training must have been completed within 1 year prior to application submission. NH Prevention Certification Board – Application for CPS (Candidates with Bachelor’s Degree) – Revised 12.9.2013 A‐5 New Hampshire Prevention Certification Board EducationDocumentation(continued) ATOD Cultural Competency Prevention Practice and Theory** Ethics*** HIV/AIDS Total Training Time Education Discipline Title Total for this page NH Prevention Certification Board – Application for CPS (Candidates with Bachelor’s Degree) – Revised 12.9.2013 A‐6 New Hampshire Prevention Certification Board EducationFormforUndocumentedEvents This form is to be used to verify undocumented education. If you do not have certificates for one or more workshops, you must fill out this form and have your supervisor or program director sign the bottom to verify that you have attended these workshops. Only 30% (36 hours) of total education can be applied with this form. PREVENTION ETHICS TRAINING MUST BE DOCUMENTED, AND MAY NOT BE LISTED ON THIS FORM. You should make every effort to locate missing verification of educational hours before using this form. This form can also be used to document in‐service trainings. Further detail about education documentation is included on page 6 of the Prevention Certification Manual. Applicant’s Name:______________________________________________________________________ Title and Sponsor of Education Date(s) Hours By signing below, I attest that the above applicant has attended the workshops and in‐service trainings listed on this page. ________________________________________________ __________________________ Signature of Supervisor or Program Director Date NH Prevention Certification Board – Application for CPS (Candidates with Bachelor’s Degree) – Revised 12.9.2013 A‐7 EducationalDisciplinesforCPSCredentials Educational disciplines* are defined as follows. Alcohol, Tobacco, and Other Drug (ATOD): The history, uses, trends and pharmacology of stimulants, depressants, psychotherapeutic drugs, alcohol, tobacco and various other substances as well as the psychological, biological and social aspects of substance abuse. Appropriate intervention for prevention and treating substance abuse in special populations is also acceptable. Cultural Competency: May focus on the aspects of culture that include not just the recognition of diversity among racial and ethnic groups and language differences, but also recognizing the importance of gender, age, socio‐economic, sexual orientation, religious, geographic and political difference across the state. Prevention Practice and Theory: Can include, but is not limited to, workshops on sustainability, planning, development, community engagement, collaboration, implementation of evidence based programs, practices and strategies, assessment, capacity building, grant writing and evaluation. Six of the required hours for initial certification must be specifically for Suicide Prevention relative to substance misuse disorders and six hours must be specifically for Violence Prevention. Violence Prevention may include sexual, domestic or bullying as long as they are for prevention specific research, strategies or interventions relative to substance misuse disorders. Ethics: Must be specific to Prevention Ethics and based on the Code of Ethical Standards for the initial certification. Recertification ethics trainings can include any ATOD related ethics workshops. HIV/AIDS: Must provide participants with basic and updated information about HIV and AIDS. This includes risk factors, modes of transmission, signs and symptoms, prevention, the relationship between HIV and AIDS, and updated information on mother‐to‐child transmission and prevention and an overview of the epidemic. *Approved by the Prevention Certification Board on 9‐10‐09; Amended 4‐21‐10, 6‐24‐13 NH Prevention Certification Board – Application for CPS (Candidates with Bachelor’s Degree) – Revised 12.9.2013 A‐8 New Hampshire Prevention Certification Board Narrative:ExperienceinthePerformanceDomains All information must be typed or printed. Incomplete applications will not be considered. In order to better learn about your experience in prevention, please take some time to complete the following narrative. Provide detailed examples of your prevention work in each of the following Performance Domains (e.g. organizations worked for, specific projects, number of years of experience). Please refer to page 8 of the Prevention Certification Manual for a description of the elements of each Domain. Please note that verbatim repetition of the definitions does not demonstrate competency. Planning and Evaluation: Prevention Education and Service Delivery: Communication: Community Organization: Public Policy and Organizational Change: Professional Growth and Responsibility: NH Prevention Certification Board – Application for CPS (Candidates with Bachelor’s Degree) – Revised 12.9.2013 A‐9 CodeofEthicalStandards This copy of the Code of Ethical Standards must be signed, notarized and returned as part of your application. Applications without a signed Code of Ethical Standards form will not be considered. A copy of the Code of Ethical Standards is also included in your Certification Manual and should be kept for your records. A. Principle 1: Non‐Discrimination 1. The Certified Prevention Specialist must not discriminate against service recipients, colleagues, or the general public based on race, religion, age, sex, national ancestry, sexual orientation, economic or handicapping conditions. 2. The Certified Prevention Specialist should broaden his or her understanding and acceptance of cultural and individual differences, in order to render services and provide information sensitive to those differences. B. Principle 2: Personal Responsibility 1. The Certified Prevention Specialist shall exercise competent professional judgment when dealing with service recipients, colleagues, or the general public and shall maintain their best interest at all times. 2. The Certified Prevention Specialist shall serve as a responsible role model in applying prevention concepts to public and professional relationships. C. Principle 3: Professional Competence 1. The Certified Prevention Specialist shall provide competent, professional service to all in keeping with the State of New Hampshire Standards. Competent professional service required: a) Thorough knowledge of ATOD abuse prevention b) Skill in presentation and education techniques c) Thoroughness and preparation reasonably necessary to assure the highest level of quality d) Service, and e) Willingness to maintain current and relevant knowledge through ongoing professional education. 2. The Certified Prevention Specialist shall assess personal competence, recognize personal boundaries and limitations, and not offer services beyond his/her skill or training level. D. Principle 4: Professional Standards The Certified Prevention Specialist (CPS) shall maintain the highest professional standards and: a) Shall not claim either directly or by implication, professional knowledge, qualifications or affiliations that the CPS does not possess. b) Shall not lend his/her name to, or participate in, any professional and/or business relationship that may knowingly misrepresent or mislead the public in any way. c) Shall not misrepresent his/her certification to the public or make false statements regarding their qualifications to the New Hampshire Prevention Certification Board. d) Must ensure that any materials or products, with which he/she is associated in developing or promoting, whether for commercial sale or other use, are presented in a professional and factual way. e) Shall recognize the effect of substance use on professional performance and must be willing to seek appropriate treatment for oneself or to support colleague in need of treatment services. f) Must fairly and accurately report appropriate prevention information to service recipients, colleagues, and the general public, acknowledging and documenting sources, materials and techniques used. g) Must not misrepresent the work of others h) Must not misrepresent one’s own prevention work for personal or professional recognition, funding, or other gain. NH Prevention Certification Board – Application for CPS (Candidates with Bachelor’s Degree) – Revised 12.9.2013 A‐10 E. Principle 5: Public Statements 1. The Certified Prevention Specialist must respect the limits of current knowledge in public statements concerning the effectiveness of prevention initiatives, prevention programs, prevention research, and ATOD information. 2. The Certified Prevention Specialist who conduct training in prevention must indicate to audience the requisite training/qualifications required to properly implement the material, program, or techniques presented/taught in training. F. Principle 6: Material Credit 1. The Certified Prevention Specialist who participates in the writing, editing, development or production of professional papers, videos/films, pamphlets, books, or any other prevention materials, must acknowledge and document any published or unpublished materials, techniques, or sources used in creating these materials. 2. The use of copyrighted materials without first receiving author approval is against the law and in violation of professional ethics. G. Principle 7: Recipient Welfare The Certified Prevention Specialist shall maintain objectivity, integrity, and the highest professional standards in: a) Delivering prevention services b) Providing supportive environment c) Protecting the welfare and upholding the best interest of both individual recipients the public d) Maintaining an objective, non‐possessive relationship with those they serve and not exploiting them sexually, financially, or emotionally. e) Maintaining an ability and willingness to make appropriate referrals. H. Principle 8: Confidentiality The Certified Prevention Specialist has the responsibility to be aware of and in compliance with all applicable state and federal guideline, regulations, statutes and agency policies, i.e. a) Notification of recipient rights b) Reporting child abuse and neglect c) Reporting misconduct by individuals or agencies d) Maintaining client confidentiality and safeguarding from disclosure confidential information acquired during service delivery. I. Principle 9: Professional Integrity The Certified Prevention Specialist should: a) Never knowingly make false statement to the appropriate licensing/certifying disciplinary authority. b) Promptly alert colleague to potentially unethical behavior so said colleague can take corrective action. c) Report violations of professional conduct by other prevention professionals to the appropriate licensing/certification disciplinary authority when there is knowledge that the said professional has violated professional standards. J. Principle 10: Remuneration 1. The Certified Prevention Specialist must establish financial arrangements in professional practice in accordance with the professional standards that safeguard the best interests of service recipients, colleagues, and the public. 2. The Certified Prevention Specialist must not send or receive and commission or rebate or any other form of remuneration for referral of service recipients for professional services. 3. The Certified Prevention Specialist must not exploit one’s relationship with service recipients to promote personal gain or the profit of any agency or commercial enterprise of any kind. NH Prevention Certification Board – Application for CPS (Candidates with Bachelor’s Degree) – Revised 12.9.2013 A‐11 K. Principle 11: Societal Obligations The Certified Prevention Specialist should: a) Advocate for consistent health promotion and awareness message to the general public b) Provide factual state‐of‐the‐art ATOD prevention information to the consumers of prevention services c) Advocate public policy that would help strengthen the overall health and well being of the community. L. Principle 12: Professional Obligations In addition to adhering to the obligations stated above, the CPS should strive to maintain and promote the integrity of certification within the State of New Hampshire, nationally and internationally, and the advancement of the ATOD prevention profession. Signature of Applicant By signing below, I attest that I have read and ascribed to this Code of Ethical Standards, as a core element of my certification as a Certified Prevention Specialist in the state of New Hampshire. _____________________________ ________________________ ____________________ Signature Print Name Date Signature of Notary Public The above candidate, in the presence of a Notary Public/Justice of the Peace, must sign this form. The Notary should sign below and affix seal. _____________________________ ________________________ ____________________ Signature Print Name Date Commission Expires NH Prevention Certification Board – Application for CPS (Candidates with Bachelor’s Degree) – Revised 12.9.2013 A‐12 New Hampshire Prevention Certification Board RecommendationForm–Page1 Name of Applicant:_____________________________________________________________________ This is a recommendation from (please circle one): Peer Supervisor I hereby waive any right to examine this letter of recommendation. I realize that the NH Prevention Certification Board will utilize this recommendation only in conjunction with consideration of Prevention Certification. I agree to the above waiver: I do not agree to the above waiver: ___________________________ ____________ ___________________________ ____________ Signature of Applicant Date Signature of Applicant Date Dear Prevention Colleague: Your cooperation in providing a candid evaluation of the above named applicant’s ability to perform as a Prevention Specialist will be appreciated. If the applicant has agreed to the above waiver, the Prevention Certification board will hold the letter confidential. When you have completed this form, please sign and return the original to the New Hampshire Prevention Certification Board. Please attach additional pages as needed to complete any narrative questions. 1. How long have you known the applicant and in what capacity? 2. In comparison with others with whom you have worked, please rate the applicant in the following areas. Unable to Below Above Average Outstanding Judge Average Average Planning and Evaluation Prevention Education and Service Delivery ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Community Organization ____ ____ ____ ____ ____ Public Policy and Organizational Change Professional Growth and Responsibility ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Communication NH Prevention Certification Board – Application for CPS (Candidates with Bachelor’s Degree) – Revised 12.9.2013 A‐13 New Hampshire Prevention Certification Board RecommendationForm–Page2 3. Please share any further observations you may have regarding the candidate’s work as a Prevention Specialist, or expand upon your ratings from question #2. 4. Please check the category below that most accurately summarizes your recommendation: ____ Highly recommended ____ Recommended ____ Recommended with reservation ____ Not recommended Signature_______________________________________ Date________________________________ Name:______________________________________ Position:________________________________ Organization/Institution:_________________________________________________________________ Address:______________________________________________________________________________ Telephone Number:_____________________________________________________________________ Email Address:_________________________________________________________________________ DO NOT RETURN TO CANDIDATE Please return both pages of recommendation to: The New Hampshire Certification Board, 501 South Street, 2nd Floor Bow, NH 03304 NH Prevention Certification Board – Application for CPS (Candidates with Bachelor’s Degree) – Revised 12.9.2013 A‐14 New Hampshire Prevention Certification Board ApplicationforCertifiedPreventionSpecialist(CPS) forCandidatesWhoDoNotHoldaBachelor’sDegreeorHigher Information must be typed or printed. Incomplete applications will not be considered. Section 1: Personal Information Name (as it should appear on your certificate):_______________________________________________ Address:______________________________________________________________________________ City/State/Zip:_________________________________________________________________________ Home Phone:__________________________ Cell Phone:_____________________________________ Email:_________________________________ Work Phone: __________________________________ Program/Business Name:________________________________________________________________ Program/Business Address:______________________________________________________________ City/State/Zip:________________________________________________________________________ Section 2: Signature Requirement I hereby certify that all of the information being submitted in this application is true and accurate, and that I have read, signed, and ascribed to the attached Code of Ethical Standards. _____________________________________________________ Applicant’s Signature __________________________ Date Certification fee is $150 for two years and is non‐refundable. Please see Page 2 of the Prevention Certification Manual for further information on fee structure. Please attach check or money order made payable to New Hampshire Prevention Certification Board. Alternatively, you can pay using PayPal by selecting the Application fee link at www.nhpreventcert.org/testing/. Completed application packets with payment can be mailed to: New Hampshire Prevention Certification Board, 501 South Street, 2nd Floor, Bow, NH 03304. NH Prevention Certification Board – Application for CPS (Candidates without Degree) – Revised 12.9.2013 A‐15 New Hampshire Prevention Certification Board PortfolioReviewChecklist Applicant’s Name: ______________________________________________________________________ APPLICATION‐ one original and two copies Completed and Signed Documentation of Name Change (if required) EXPERIENCE Total Number of Hours Three (3) Recommendation Forms on File (forms should be sent directly to the Cert Board from the reference) Narrative completed and Attached Resume and Job description(s) Attached Not to be sent in by Applicant SUPERVISED PRACTICAL EXPERIENCE Total Number of Hours CODE OF ETHICAL STANDARDS Signed and Notarized EDUCATION Total Number of hours ATOD hours Cultural Competency hours Prevention Practice and Theory hours Suicide Prevention Violence Prevention HIV/AIDS Training hours Prevention Ethics Training hours College Transcript (or Ed Waiver Form) Attached Certification Staff Use Only Applicant TESTING AND REVIEW (exam can be taken within 6 months prior to or after submitting application) Passed IC&RC Prevention Specialist Exam This checklist should be the second document in your application packet. This checklist provides a location for you to record compliance with certification criteria, and a location for NH Prevention Certification Board staff to record the outcome for their review of the documents you have submitted. NH Prevention Certification Board – Application for CPS (Candidates without Degree) – Revised 12.9.2013 A‐16 New Hampshire Prevention Certification Board DocumentationofExperience In cases where an applicant has had experience at more than one site/employer, a separate form should be filled out for each location of experience. Please note that a copy of the applicant’s resume must be attached to this form. All information must be typed or printed. Section 1: Applicant Information Name:________________________________________________________________________________ Section 2: Program Information Program Name: ________________________________________________________________________ Program Address:______________________________________________________________________ City/State/Zip:_________________________________________________________________________ Daytime Phone Number:_________________________________________________________________ Section 3: Documentation of Experience Please attach a copy of the applicant’s job description on, or attached to, program letterhead. Applicant’s Position:____________________________________________________________________ Start Date:_______________________________ End Date:_______________________________ Average Weekly Schedule (hours)*:________________________________________________________ * Experience hours are calculated based on start/end dates and average weekly schedule. Indicate the average number of direct and indirect hours per week the applicant spent in the ATOD prevention activities of planning and evaluation, education and skill development, community organization, public policy, and professional growth and responsibility. Full time ATOD Prevention Specialists may enter 40 hours. Section 4: Signature Requirement By signing below, I attest that the applicant named in Section I worked as a prevention professional at this program providing prevention services, and I endorse this candidate for certification. ________________________________________________ Signature of Supervisor or Program Director __________________________ Date Certified Prevention Specialists who do not hold a Bachelor’s degree or higher are required to have 4,000 hours of ATOD‐related Prevention experience. NOTE: Volunteer experience can only count for 50% of total experience (2000 hours). The Program Director or Supervisor of the program in which the experience was gained should complete this form. If the experience was in several programs, each of them should complete copies of this form. SUPERVISOR: Please complete and sign this form and return it to the applicant with a copy of the applicant’s job description, for submission with his/her Certification Application. APPLICANT: Please enter the total number of documented experience hours on the Applicant Checklist. NH Prevention Certification Board – Application for CPS (Candidates without Degree) – Revised 12.9.2013 A‐17 New Hampshire Prevention Certification Board DocumentationofSupervision In cases where an applicant has had supervision by multiple supervisors (due to multiple employers/programs), each supervisor should fill out a separate form. All information must be typed or printed. Section 1: Applicant Information Name:________________________________________________________________________________ Section 2: Program Information Program Name: ________________________________________________________________________ Program Address:______________________________________________________________________ City/State/Zip:_________________________________________________________________________ Daytime Phone Number:_________________________________________________________________ Section 3: Documentation of Experience Indicate the total number of hours Supervision for each of the Prevention Performance Domains* listed: 1. Planning and Evaluation 2. Prevention Education and Service Delivery ______hours 3. Communications 3. Community Organization 4. Public Policy and Organizational Change ______hours 5. Professional Growth and Responsibility ______hours ______hours ______hours ______hours TOTAL ______hours *Please consult with the prevention certification applicant if additional information regarding the content of the Performance Domain is needed. Section 4: Signature Requirement By signing below, I attest that the applicant received supervision in the Performance Domains as listed above, and I endorse this candidate for certification. ________________________________________________ Signature of Supervisor or Program Director __________________________ Date Certified Prevention Specialists who do not hold a Bachelor’s degree or higher must have 240 hours of Supervision in the Prevention Performance Domains, with at least 20 hours in each of the listed Performance Domains. The person or persons supervising the applicant should complete this form or forms. SUPERVISOR: Please return the completed form to the applicant for submission with his/her application. APPLICANT: Transfer the total number of Supervised Practical Training hours to the Application Check List. NH Prevention Certification Board – Application for CPS (Candidates without Degree) – Revised 12.9.2013 A‐18 New Hampshire Prevention Certification Board EducationDocumentation Please review pages 5 through 6 of the Prevention Certification Manual before completing this form. Education is defined as formal, structured instruction in the form of workshops, seminars, institutes, in‐services, college/university credit courses and Prevention Certification Board approved distance education. Further detail about the various types of allowable education is included on page 5 of the Prevention Certification Manual. Educational Disciplines are defined on page 8 of this application packet and on page 10 of the Prevention Certification Manual, specific hour requirements are detailed in the chart below. The next page can be copied to allow for more entries. ATOD Cultural Competency Prevention Practice and Theory** Ethics*** HIV/AIDS Total Training Time 50 15 43 6 6 240 6 6 6 Total for this page Total for all pages Education Discipline Title Total Hours Required (see note below)* Example: Understanding Coalition Building Theory and Practice Example: Prevention Ethics * Total training in this column must equal 240 hours for those who do not hold a Bachelor’s degree or higher. In addition to the hourly requirements by discipline, another 120 hours across the disciplines is required See manual for education requirements in lieu of a bachelor’s degree. **Prevention Practice and Theory must include 6 hours of Suicide Prevention Training and 6 hours of Violence Prevention Training *** Prevention Ethics Training must have been completed within 1 year prior to application submission. NH Prevention Certification Board – Application for CPS (Candidates without Degree) – Revised 12.9.2013 A‐19 New Hampshire Prevention Certification Board EducationDocumentation(continued) ATOD Cultural Competency Prevention Practice and Theory** Ethics*** HIV/AIDS Total Training Time Education Discipline Title Total for this page NH Prevention Certification Board – Application for CPS (Candidates without Degree) – Revised 12.9.2013 A‐20 New Hampshire Prevention Certification Board EducationFormforUndocumentedEvents This form is to be used to verify undocumented education. If you do not have certificates for one or more workshops, you must fill out this form and have your supervisor or program director sign the bottom to verify that you have attended these workshops. Only 30% (72 hours) of total education can be applied with this form. PREVENTION ETHICS TRAINING MUST BE DOCUMENTED, AND MAY NOT BE LISTED ON THIS FORM. You should make every effort to locate missing verification of educational hours before using this form. This form can also be used to document in‐service trainings. Further detail about education documentation is included on page 6 of the Prevention Certification Manual. Applicant’s Name:______________________________________________________________________ Title and Sponsor of Education Date(s) Hours By signing below, I attest that the above applicant has attended the workshops and in‐service trainings listed on this page. ________________________________________________ __________________________ Signature of Supervisor or Program Director Date NH Prevention Certification Board – Application for CPS (Candidates without Degree) – Revised 12.9.2013 A‐21 EducationalDisciplinesforCPSCredentials Educational disciplines* are defined as follows. Alcohol, Tobacco, and Other Drug (ATOD): The history, uses, trends and pharmacology of stimulants, depressants, psychotherapeutic drugs, alcohol, tobacco and various other substances as well as the psychological, biological and social aspects of substance abuse. Appropriate intervention for prevention and treating substance abuse in special populations is also acceptable. Cultural Competency: May focus on the aspects of culture that include not just the recognition of diversity among racial and ethnic groups and language differences, but also recognizing the importance of gender, age, socio‐economic, sexual orientation, religious, geographic and political difference across the state. Prevention Practice and Theory: Can include, but is not limited to, workshops on sustainability, planning, development, community engagement, collaboration, implementation of evidence based programs, practices and strategies, assessment, capacity building, grant writing and evaluation. Six of the required hours for initial certification must be specifically for Suicide Prevention relative to substance misuse disorders and six hours must be specifically for Violence Prevention. Violence Prevention may include sexual, domestic or bullying as long as they are for prevention specific research, strategies or interventions relative to substance misuse disorders. Ethics: Must be specific to Prevention Ethics and based on the Code of Ethical Standards for the initial certification. Recertification ethics trainings can include any ATOD related ethics workshops. HIV/AIDS: Must provide participants with basic and updated information about HIV and AIDS. This includes risk factors, modes of transmission, signs and symptoms, prevention, the relationship between HIV and AIDS, and updated information on mother‐to‐child transmission and prevention and an overview of the epidemic. *Approved by the Prevention Certification Board on 9‐10‐09; Amended 4‐21‐10, 6‐24‐13 NH Prevention Certification Board – Application for CPS (Candidates without Degree) – Revised 12.9.2013 A‐22 New Hampshire Prevention Certification Board Narrative:ExperienceinthePerformanceDomains All information must be typed or printed. Incomplete applications will not be considered. In order to better learn about your experience in prevention, please take some time to complete the following narrative. Provide detailed examples of your prevention work in each of the following Performance Domains (e.g. organizations worked for, specific projects, number of years of experience). Please refer to page 8 of the Prevention Certification Manual for a description of the elements of each Domain. Please note that verbatim repetition of the definitions does not demonstrate competency. Planning and Evaluation: Prevention Education and Service Delivery: Communication: Community Organization: Public Policy and Organizational Change: Professional Growth and Responsibility: NH Prevention Certification Board – Application for CPS (Candidates without Degree) – Revised 12.9.2013 A‐23 CodeofEthicalStandards This copy of the Code of Ethical Standards must be signed, notarized and returned as part of your application. Applications without a signed Code of Ethical Standards form will not be considered. A copy of the Code of Ethical Standards is also included in your Certification Manual and should be kept for your records. E. Principle 1: Non‐Discrimination 1. The Certified Prevention Specialist must not discriminate against service recipients, colleagues, or the general public based on race, religion, age, sex, national ancestry, sexual orientation, economic or handicapping conditions. 2. The Certified Prevention Specialist should broaden his or her understanding and acceptance of cultural and individual differences, in order to render services and provide information sensitive to those differences. F. Principle 2: Personal Responsibility 1. The Certified Prevention Specialist shall exercise competent professional judgment when dealing with service recipients, colleagues, or the general public and shall maintain their best interest at all times. 2. The Certified Prevention Specialist shall serve as a responsible role model in applying prevention concepts to public and professional relationships. G. Principle 3: Professional Competence 1. The Certified Prevention Specialist shall provide competent, professional service to all in keeping with the State of New Hampshire Standards. Competent professional service required: a) Thorough knowledge of ATOD abuse prevention b) Skill in presentation and education techniques c) Thoroughness and preparation reasonably necessary to assure the highest level of quality d) Service, and e) Willingness to maintain current and relevant knowledge through ongoing professional education. 2. The Certified Prevention Specialist shall assess personal competence, recognize personal boundaries and limitations, and not offer services beyond his/her skill or training level. H. Principle 4: Professional Standards The Certified Prevention Specialist (CPS) shall maintain the highest professional standards and: i) Shall not claim either directly or by implication, professional knowledge, qualifications or affiliations that the CPS does not possess. j) Shall not lend his/her name to, or participate in, any professional and/or business relationship that may knowingly misrepresent or mislead the public in any way. k) Shall not misrepresent his/her certification to the public or make false statements regarding their qualifications to the New Hampshire Prevention Certification Board. l) Must ensure that any materials or products, with which he/she is associated in developing or promoting, whether for commercial sale or other use, are presented in a professional and factual way. m) Shall recognize the effect of substance use on professional performance and must be willing to seek appropriate treatment for oneself or to support colleague in need of treatment services. n) Must fairly and accurately report appropriate prevention information to service recipients, colleagues, and the general public, acknowledging and documenting sources, materials and techniques used. o) Must not misrepresent the work of others p) Must not misrepresent one’s own prevention work for personal or professional recognition, funding, or other gain. NH Prevention Certification Board – Application for CPS (Candidates without Degree) – Revised 12.9.2013 A‐24 E. Principle 5: Public Statements 3. The Certified Prevention Specialist must respect the limits of current knowledge in public statements concerning the effectiveness of prevention initiatives, prevention programs, prevention research, and ATOD information. 4. The Certified Prevention Specialist who conduct training in prevention must indicate to audience the requisite training/qualifications required to properly implement the material, program, or techniques presented/taught in training. K. Principle 6: Material Credit 1. The Certified Prevention Specialist who participates in the writing, editing, development or production of professional papers, videos/films, pamphlets, books, or any other prevention materials, must acknowledge and document any published or unpublished materials, techniques, or sources used in creating these materials. 2. The use of copyrighted materials without first receiving author approval is against the law and in violation of professional ethics. L. Principle 7: Recipient Welfare The Certified Prevention Specialist shall maintain objectivity, integrity, and the highest professional standards in: a) Delivering prevention services b) Providing supportive environment c) Protecting the welfare and upholding the best interest of both individual recipients the public d) Maintaining an objective, non‐possessive relationship with those they serve and not exploiting them sexually, financially, or emotionally. e) Maintaining an ability and willingness to make appropriate referrals. M. Principle 8: Confidentiality The Certified Prevention Specialist has the responsibility to be aware of and in compliance with all applicable state and federal guideline, regulations, statutes and agency policies, i.e. a) Notification of recipient rights b) Reporting child abuse and neglect c) Reporting misconduct by individuals or agencies d) Maintaining client confidentiality and safeguarding from disclosure confidential information acquired during service delivery. N. Principle 9: Professional Integrity The Certified Prevention Specialist should: a) Never knowingly make false statement to the appropriate licensing/certifying disciplinary authority. b) Promptly alert colleague to potentially unethical behavior so said colleague can take corrective action. c) Report violations of professional conduct by other prevention professionals to the appropriate licensing/certification disciplinary authority when there is knowledge that the said professional has violated professional standards. O. Principle 10: Remuneration 1. The Certified Prevention Specialist must establish financial arrangements in professional practice in accordance with the professional standards that safeguard the best interests of service recipients, colleagues, and the public. 2. The Certified Prevention Specialist must not send or receive and commission or rebate or any other form of remuneration for referral of service recipients for professional services. 3. The Certified Prevention Specialist must not exploit one’s relationship with service recipients to promote personal gain or the profit of any agency or commercial enterprise of any kind. NH Prevention Certification Board – Application for CPS (Candidates without Degree) – Revised 12.9.2013 A‐25 K. Principle 11: Societal Obligations The Certified Prevention Specialist should: d) Advocate for consistent health promotion and awareness message to the general public e) Provide factual state‐of‐the‐art ATOD prevention information to the consumers of prevention services f) Advocate public policy that would help strengthen the overall health and well being of the community. L. Principle 12: Professional Obligations In addition to adhering to the obligations stated above, the CPS should strive to maintain and promote the integrity of certification within the State of New Hampshire, nationally and internationally, and the advancement of the ATOD prevention profession. Signature of Applicant By signing below, I attest that I have read and ascribed to this Code of Ethical Standards, as a core element of my certification as a Certified Prevention Specialist in the state of New Hampshire. _____________________________ ________________________ ____________________ Signature Print Name Date Signature of Notary Public The above candidate, in the presence of a Notary Public/Justice of the Peace, must sign this form. The Notary should sign below and affix seal. _____________________________ ________________________ ____________________ Signature Print Name Date Commission Expires NH Prevention Certification Board – Application for CPS (Candidates without Degree) – Revised 12.9.2013 A‐26 New Hampshire Prevention Certification Board RecommendationForm–Page1 Name of Applicant:_____________________________________________________________________ This is a recommendation from (please circle one): Peer Supervisor I hereby waive any right to examine this letter of recommendation. I realize that the NH Prevention Certification Board will utilize this recommendation only in conjunction with consideration of Prevention Certification. I agree to the above waiver: I do not agree to the above waiver: ___________________________ ____________ ___________________________ ____________ Date Signature of Applicant Date Signature of Applicant Dear Prevention Colleague: Your cooperation in providing a candid evaluation of the above named applicant’s ability to perform as a Prevention Specialist will be appreciated. If the applicant has agreed to the above waiver, the Prevention Certification board will hold the letter confidential. When you have completed this form, please sign and return the original to the New Hampshire Prevention Certification Board. Please attach additional pages as needed to complete any narrative questions. 5. How long have you known the applicant and in what capacity? 6. In comparison with others with whom you have worked, please rate the applicant in the following areas. Unable to Below Above Average Outstanding Judge Average Average Planning and Evaluation Prevention Education and Service Delivery ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Community Organization ____ ____ ____ ____ ____ Public Policy and Organizational Change Professional Growth and Responsibility ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Communication NH Prevention Certification Board – Application for CPS (Candidates without Degree) – Revised 12.9.2013 A‐27 New Hampshire Prevention Certification Board RecommendationForm–Page2 7. Please share any further observations you may have regarding the candidate’s work as a Prevention Specialist, or expand upon your ratings from question #2. 8. Please check the category below that most accurately summarizes your recommendation: ____ Highly recommended ____ Recommended ____ Recommended with reservation ____ Not recommended Signature_______________________________________ Date________________________________ Name:______________________________________ Position:________________________________ Organization/Institution:_________________________________________________________________ Address:______________________________________________________________________________ Telephone Number:_____________________________________________________________________ Email Address:_________________________________________________________________________ DO NOT RETURN TO CANDIDATE Please return both pages of recommendation to: The New Hampshire Certification Board, 501 South Street, 2nd Floor, Bow, NH 03304 NH Prevention Certification Board – Application for CPS (Candidates without Degree) – Revised 12.9.2013 A‐28 New Hampshire Prevention Certification Board RegistrationforIC&RCExamforCertifiedPreventionSpecialist(CPS) Information must be typed or printed. Name (as it should appear on your certificate):_______________________________________________ Address:______________________________________________________________________________ City/State/Zip:_________________________________________________________________________ Home Phone:__________________________ Cell Phone:_____________________________________ Email:__________________________________ Work Phone: _________________________________ Program/Business Name:________________________________________________________________ Program/Business Address:______________________________________________________________ City/State/Zip:_________________________________________________________________________ A non‐refundable $150 certification fee is required when scheduling the exam or at the time of application. The certification fee includes IC&RC reciprocity and examination fee. Applicants who do not pass the IC&RC exam on the initial attempt will be charged $80 to retake the exam within 6 months of the initial exam date. If you do not submit your application within 6 months of taking and passing the exam, you will need to re‐take the exam and will be charged $150 to do so. Insufficient applications will be returned for completion and a $25 fee will be assessed for each subsequent review. The IC&RC exam is offered quarterly: March, June, September and December. Specific dates and deadlines for registration are posted on the NH Prevention Certification Board website at www.nhpreventcert.org/testing/. Regardless of when the exam is taken, your certification is not effective until your application is submitted and approved by the Peer Review Committee. Certification dates are recorded based on the completion and approval of applications and passage of the IC&RC exam. I would like to be scheduled for my IC&RC exam on the following quarterly date: ______March ______June ______September ______December By signing below, I acknowledge that I understand the above rules and regulations of the NH Prevention Certification Board, an IC&RC member board. ________________________________________________ Registrant’s Signature __________________________ Date Completed registration form can be mailed to: the New Hampshire Prevention Certification Board, 501 South Street, 2nd Floor, Bow, NH 03304 or scanned and e‐mailed to [email protected]. If paying by check, please make payable to New Hampshire Prevention Certification Board. Alternatively, you can pay using PayPal by selecting the Application fee link at www.nhpreventcert.org/testing/. NH Prevention Certification Board – Registration for IC&RC Exam for CPS – Revised 12.2.2013 A‐29 NH Prevention Certification Board RecertificationApplicationforCertifiedPreventionSpecialist(CPS) Information must be typed or printed. Incomplete applications will not be considered. Please document Continuing Education hours on page 2. Be sure to attach copies of certificates and syllabus, agenda or outline of workshops as proof of completion. Section 1: Personal Information Name (as it should appear on your certificate):_______________________________________________ Certificate Expiration:______________________ Address:______________________________________________________________________________ City/State/Zip:_________________________________________________________________________ Home Phone:____________________________ Cell Phone:___________________________________ Email:__________________________________ Work Phone:__________________________________ Program/Business Name:________________________________________________________________ Program/Business Address:_______________________________________________________________ City/State/Zip:_________________________________________________________________________ Section 2: Fees Enclosed Recertification Fee: Late Fee (if applicable): $75.00 $25.00 _________ _________ Total Enclosed: _________ Section 3: Signature Requirement I hereby certify that all of the information being submitted in this application is true and accurate, and that I have read, signed, and ascribed to the attached Code of Ethical Standards. ________________________________________________ Applicant’s Signature __________________________ Date Please return one original to The New Hampshire Certification Board 501 South Street, 2nd Floor Bow, NH 03304 NH Prevention Certification Board – Application for CPS Recertification – Revised 12.9.2013 A‐30 New Hampshire Prevention Certification Board RecertificationContinuingEducationDocumentation ATOD Cultural Competency Prevention Practice and Theory Ethics HIV/AIDS Total Training Time Effective 1/1/2014, 6 hours of Ethics training is required for recertification. Also effective 1/1/14, 6 hours of Suicide Prevention training* and 6 hours of Violence Prevention training* (within the required 40 hours of training) is required for recertification. *In lieu of the new training requirements for Suicide and Violence prevention, applicants may present documentation of previous trainings for Suicide and Violence prevention going back to their original certification application. These cannot be undocumented hours. Up to 12 of the 40 required hours of education for recertification may be received for hours teaching. Please refer to the full CPS Manual for more details regarding recertification. 12 6 40 6 6 Education Discipline Title Total Hours Required (see note below) Example: Prevention Ethics Total NH Prevention Certification Board – Application for CPS Recertification – Revised 12.9.2013 A‐31 New Hampshire Prevention Certification Board EducationFormforUndocumentedEvents This form is to be used to verify undocumented education. If you do not have certificates for one or more workshops, you must fill out this form and have your supervisor or program director sign the bottom to verify that you have attended these workshops. Only 30% of total education can be applied with this form. PREVENTION ETHICS TRAINING MUST BE DOCUMENTED, AND MAY NOT BE LISTED ON THIS FORM. You should make every effort to locate missing verification of educational hours before using this form. This form can also be used to document in‐service trainings. Further detail about education documentation is included on page 6 of the Prevention Certification Manual. Applicant’s Name:______________________________________________________________________ Title and Sponsor of Education Date(s) Hours By signing below, I attest that the above applicant has attended the workshops and in‐service trainings listed on this page. ________________________________________________ __________________________ Signature of Supervisor or Program Director Date NH Prevention Certification Board – Application for CPS Recertification – Revised 12.9.2013 A‐32 CodeofEthicalStandards This copy of the Code of Ethical Standards must be signed, notarized and returned as part of your application. Applications without a signed Code of Ethical Standards form will not be considered. A copy of the Code of Ethical Standards is also included in your Certification Manual and should be kept for your records. I. Principle 1: Non‐Discrimination 1. The Certified Prevention Specialist must not discriminate against service recipients, colleagues, or the general public based on race, religion, age, sex, national ancestry, sexual orientation, economic or handicapping conditions. 2. The Certified Prevention Specialist should broaden his or her understanding and acceptance of cultural and individual differences, in order to render services and provide information sensitive to those differences. J. Principle 2: Personal Responsibility 1. The Certified Prevention Specialist shall exercise competent professional judgment when dealing with service recipients, colleagues, or the general public and shall maintain their best interest at all times. 2. The Certified Prevention Specialist shall serve as a responsible role model in applying prevention concepts to public and professional relationships. K. Principle 3: Professional Competence 1. The Certified Prevention Specialist shall provide competent, professional service to all in keeping with the State of New Hampshire Standards. Competent professional service required: a) Thorough knowledge of ATOD abuse prevention b) Skill in presentation and education techniques c) Thoroughness and preparation reasonably necessary to assure the highest level of quality d) Service, and e) Willingness to maintain current and relevant knowledge through ongoing professional education. 2. The Certified Prevention Specialist shall assess personal competence, recognize personal boundaries and limitations, and not offer services beyond his/her skill or training level. L. Principle 4: Professional Standards The Certified Prevention Specialist (CPS) shall maintain the highest professional standards and: q) Shall not claim either directly or by implication, professional knowledge, qualifications or affiliations that the CPS does not possess. r) Shall not lend his/her name to, or participate in, any professional and/or business relationship that may knowingly misrepresent or mislead the public in any way. s) Shall not misrepresent his/her certification to the public or make false statements regarding their qualifications to the New Hampshire Prevention Certification Board. t) Must ensure that any materials or products, with which he/she is associated in developing or promoting, whether for commercial sale or other use, are presented in a professional and factual way. u) Shall recognize the effect of substance use on professional performance and must be willing to seek appropriate treatment for oneself or to support colleague in need of treatment services. v) Must fairly and accurately report appropriate prevention information to service recipients, colleagues, and the general public, acknowledging and documenting sources, materials and techniques used. w) Must not misrepresent the work of others x) Must not misrepresent one’s own prevention work for personal or professional recognition, funding, or other gain. NH Prevention Certification Board – Application for CPS Recertification – Revised 12.9.2013 A‐33 E. Principle 5: Public Statements 5. The Certified Prevention Specialist must respect the limits of current knowledge in public statements concerning the effectiveness of prevention initiatives, prevention programs, prevention research, and ATOD information. 6. The Certified Prevention Specialist who conduct training in prevention must indicate to audience the requisite training/qualifications required to properly implement the material, program, or techniques presented/taught in training. P. Principle 6: Material Credit 1. The Certified Prevention Specialist who participates in the writing, editing, development or production of professional papers, videos/films, pamphlets, books, or any other prevention materials, must acknowledge and document any published or unpublished materials, techniques, or sources used in creating these materials. 2. The use of copyrighted materials without first receiving author approval is against the law and in violation of professional ethics. Q. Principle 7: Recipient Welfare The Certified Prevention Specialist shall maintain objectivity, integrity, and the highest professional standards in: a) Delivering prevention services b) Providing supportive environment c) Protecting the welfare and upholding the best interest of both individual recipients the public d) Maintaining an objective, non‐possessive relationship with those they serve and not exploiting them sexually, financially, or emotionally. e) Maintaining an ability and willingness to make appropriate referrals. R. Principle 8: Confidentiality The Certified Prevention Specialist has the responsibility to be aware of and in compliance with all applicable state and federal guideline, regulations, statutes and agency policies, i.e. a) Notification of recipient rights b) Reporting child abuse and neglect c) Reporting misconduct by individuals or agencies d) Maintaining client confidentiality and safeguarding from disclosure confidential information acquired during service delivery. S. Principle 9: Professional Integrity The Certified Prevention Specialist should: a) Never knowingly make false statement to the appropriate licensing/certifying disciplinary authority. b) Promptly alert colleague to potentially unethical behavior so said colleague can take corrective action. c) Report violations of professional conduct by other prevention professionals to the appropriate licensing/certification disciplinary authority when there is knowledge that the said professional has violated professional standards. T. Principle 10: Remuneration 1. The Certified Prevention Specialist must establish financial arrangements in professional practice in accordance with the professional standards that safeguard the best interests of service recipients, colleagues, and the public. 2. The Certified Prevention Specialist must not send or receive and commission or rebate or any other form of remuneration for referral of service recipients for professional services. 3. The Certified Prevention Specialist must not exploit one’s relationship with service recipients to promote personal gain or the profit of any agency or commercial enterprise of any kind. NH Prevention Certification Board – Application for CPS Recertification – Revised 12.9.2013 A‐34 K. Principle 11: Societal Obligations The Certified Prevention Specialist should: g) Advocate for consistent health promotion and awareness message to the general public h) Provide factual state‐of‐the‐art ATOD prevention information to the consumers of prevention services i) Advocate public policy that would help strengthen the overall health and well being of the community. L. Principle 12: Professional Obligations In addition to adhering to the obligations stated above, the CPS should strive to maintain and promote the integrity of certification within the State of New Hampshire, nationally and internationally, and the advancement of the ATOD prevention profession. Signature of Applicant By signing below, I attest that I have read and ascribed to this Code of Ethical Standards, as a core element of my certification as a Certified Prevention Specialist in the state of New Hampshire. _____________________________ ________________________ ____________________ Signature Print Name Date Signature of Notary Public The above candidate, in the presence of a Notary Public/Justice of the Peace, must sign this form. The Notary should sign below and affix seal. _____________________________ ________________________ ____________________ Signature Print Name Date Commission Expires NH Prevention Certification Board – Application for CPS Recertification – Revised 12.9.2013 A‐35
© Copyright 2024