Application for Certified Prevention Specialist (CPS)

Application for Certified Prevention Specialist (CPS)

Personal Information

Name (as it should appear on your certificate)*

Date of Application*

Home Address*

Please include your full home address, with city/state/zip

Home Phone

Phone

Cell Phone

Phone

Work Phone

Phone

Email Address*

Please include an email address you check regularly. This will be the CPS Board's primary form of contact with applicants.

Current Workplace or Program*

Position/Title*

Workplace/Business Address*

Please include full address, with city/state/zip

Demographics

Years Working in Prevention*

Please select the option that best describes you.

0-3 years

4-7 years

8-10 years

10+ years

Highest Degree of Education

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What race best describes you?*

Please select the option that best describes you.

Are you Hispanic/Latino?*

Please select the option that best describes you.

Yes

I prefer not to respond

Personal Armed Forces Service*

Please select the option that best describes you.

I am a current member of the armed forces

I am a veteran

I am not a current member or veteran of the armed forces

I prefer not to respond

Do you have a family member who is in the military or is a veteran?*

Yes

I prefer not to respond

Fee Structure and Payment

Certification is valid for two years. Initial application fees are $300 and includes application review, and exam fee. Application fees are non-refundable. Applicants who do not pass the IC&RC exam on the initial attempt will be charged $150 to retake the exam within 6 months of initial exam date. Applications must be complete and approved within 6 months of passing the exam. If not submitted and approved within the 6 months, you will need to retake the exam and will be charged $300 to do so. For this reason, we recommend submitting your application prior to taking the exam. Once your application is approved, Prevention Works!VT staff will help the applicant register for the exam. Insufficient or incomplete applications will be returned for completion and a $50 fee may be assessed for each subsequent review.

Checks may be made out to The Collaborative and mailed to 91 VT Route 11 Londonderry VT 05148. Please include CPS certification and the applicant's name in the memo line.

Please contact cps@preventionworksvermont.org with any questions or to make other payment arrangements. Card payments are accepted through Venmo with prior arrangements with Prevention Works!VT staff through this email address. If your workplace is paying for your certification fees, please let PW staff know using this email address what business will be submitting the payment so we can match payment to your application.

Yes I have paid my application fee*

File Upload

Please attach the following documents here to support your application:

Portfolio Review Checklist
Documentation of Supervision Form
Applicant's Job Description
Education Documentation Form
Certificates of Attendance
Education Form for Undocumented Events (if needed)
Signed Code of Ethical Standards
Narrative Experience
Recommendations
signed supervision form(s)

File Upload*

Drag and drop files here or

The Portfolio Checklist

Be sure that you have all the information required before submitting your application.

Portfolio Checklist

Supervision

Supervision is a formal or informal process that is administrative, evaluative, and supportive. It can be provided by more than one person, it ensures quality of services, and extends over time. Supervision includes observation, mentoring, coaching, evaluating, inspiring, and creating an atmosphere that promotes self-motivation, learning, and professional development. In all aspects of the supervision process, ethical and diversity issues must be the forefront.

Supervision Required: 120 hours with a minimum of 10 hours in each domain. Hours may be included in the total experience requirement. Supervisors must complete this separate supervisor document and submit to the CPS board.

Supervisor Position/Title*

Employer Name*

Employer Address*

Supervisor's Email*

Supervisor's Phone

Phone

Yes, I have requested my supervision form*

Code of Ethics

This copy of the Code of Ethical Standards must be signed as part of your application. Applications without a signed Code of Ethical Standards will not be accepted.

Yes, I have uploaded my signed Code of Ethical Standards*

Attestation

I hearby 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 Prevention Code of Ethical Standards.*

Select

Education Documentation

Please use this documentation form to document required education hours. The minimum required CEUs is 175 hours with at least 6 hours in each domain, as well as 6 in Prevention Ethics. At least 24 hours must be ATOD specific. For every training in this document, you will also need to upload proof of attendance.

If you do not have documentation for an education event, you may complete the undocumented education form. You may complete this form for one or more workshops that you do not have certificates for, and your supervisor must sign to verify your attendance. No more than 30% (52 total education hours) may be applied with this form. Prevention Ethics must be documented and may not be recorded on this form.

Yes, I have uploaded my education documentation*

Narrative: Experience in the Performance Domains

In order to better learn about your experience in prevention, please complete this narrative document. In your 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.) Limit your narrative.

Please note that verbatim repitition of the definitions does not demonstrate competency.

Yes, I have uploaded my narrative experience*

Recommendations

Recommendations should be provided and returned by the person providing the recommendation using this link. You do not need to collect the recommendation to submit yourself. Recommendations submitted by the applicant will not be considered. Please request 2 recommdation forms:

A prevention colleague, other peer, board member, or an organizational recipient of services
Supervisor who can describe your experience in domains

Recommendation Form

Yes, I have requested two recommendation forms*

Authorization and Release Form*

AUTHORIZATION AND RELEASE FORM

I hereby authorize the Vermont Prevention Certification Board (VPCB) to make any inquiry of any agency, facility, organization or individual for any and all additional information which might be necessary to fully and properly evaluate my application for the Certified Prevention Specialist (CPS).

I hereby release and hold harmless the VCPB, Board Members, its Officers, its employees, servants, and agents from any and all manner of suits, actions, claims, and judgments which might arise from such efforts to further document the statements and claims I have made in this application or in the processing or consideration of same. I will also hold these same parties free from any civil liability for damages or complaints by reason of any action that is within their scope and arising out of the performance of their duties which they, or any of them, may take in connection with any examination, and/or failure of the Board to bestow upon me certification with the VCPB, the IC&RC, Vermont Department of Health, the Collaborative or any other entity.

I also affirm that I conform to the Prevention Code of Ethics's requirements for credentialing.

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Send me a copy of my responses

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