New York State Office of Alcoholism and Substance Abuse Services s1
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New York State Office of Alcoholism and Substance Abuse Services Education and Training Provider Certification Application PART D – CPP 250-HOUR CERTIFICATE PROGRAM INFORMATION (please type all information)
EDUCATION AND TRAINING PROVIDER:
CPP 250-HOUR CERTIFICATE PROGRAM INFORMATION
SECTION I – KNOWLEDGE OF ALCOHOL AND SUBSTANCE ABUSE AT ALL AGE LEVELS AND AMONG PEOPLE OF DIVERSE BACKGROUNDS AND CULTURES (85 CLOCK HOURS)
NUMBER OF CLOCK HOURS
ATTACHED FOR PREVIOUSLY PENDING REVIEW AND TITLE OF COURSE/TRAINING APPROVED APPROVAL APPROVAL
TOTALS COLUMN TOTAL COLUMN TOTAL COLUMN TOTAL SECTION TOTAL
INFORMATION ON NEXT PAGE MUST BE COMPLETED
PDS-17.5 (05/04) 1 New York State Office of Alcoholism and Substance Abuse Services Education and Training Provider Certification Application PART D – CPP 250-HOUR CERTIFICATE PROGRAM INFORMATION (please type all information)
EDUCATION AND TRAINING PROVIDER:
CPP 250-HOUR CERTIFICATE PROGRAM INFORMATION
SECTION II – PREVENTION SPECIFIC AND RELATED TO THE FIVE PERFORMANCE DOMAINS (AREAS OF PROFESSIONAL EXPERTISE) (60 CLOCK HOURS)
NUMBER OF CLOCK HOURS
ATTACHED FOR PREVIOUSLY PENDING REVIEW AND TITLE OF COURSE/TRAINING APPROVED APPROVAL APPROVAL
TOTALS COLUMN TOTAL COLUMN TOTAL COLUMN TOTAL SECTION TOTAL
INFORMATION ON NEXT PAGE MUST BE COMPLETED
PDS-17.5 (05/04) 2 New York State Office of Alcoholism and Substance Abuse Services Education and Training Provider Certification Application PART D – CPP 250-HOUR CERTIFICATE PROGRAM INFORMATION (please type all information)
EDUCATION AND TRAINING PROVIDER:
CPP 250-HOUR CERTIFICATE PROGRAM INFORMATION
SECTION III – PROFESSIONAL DEVELOPMENT AND ETHICAL RESPONSIBILITIES (45 CLOCK HOURS, INCLUDING A MINIMUM OF 12 CLOCK HOURS FOCUSED ON INDIVIDUAL AND PROGRAM ETHICS)
NUMBER OF CLOCK HOURS
ATTACHED FOR PREVIOUSLY PENDING REVIEW AND TITLE OF COURSE/TRAINING APPROVED APPROVAL APPROVAL
TOTALS COLUMN TOTAL COLUMN TOTAL COLUMN TOTAL SECTION TOTAL
INFORMATION ON NEXT PAGE MUST BE COMPLETED
PDS-17.5 (05/04) 3 New York State Office of Alcoholism and Substance Abuse Services Education and Training Provider Certification Application PART D – CPP 250-HOUR CERTIFICATE PROGRAM INFORMATION (please type all information)
EDUCATION AND TRAINING PROVIDER:
CPP 250-HOUR CERTIFICATE PROGRAM INFORMATION
SECTION IV – PREVENTION PRINCIPLES AND PRACTICES AND THE SERVICES CONTINUUM (60 CLOCK HOURS)
NUMBER OF CLOCK HOURS
ATTACHED FOR PREVIOUSLY PENDING REVIEW AND TITLE OF COURSE/TRAINING APPROVED APPROVAL APPROVAL
TOTALS COLUMN TOTAL COLUMN TOTAL COLUMN TOTAL SECTION TOTAL
CERTIFICATE PROGRAM TOTAL (SUM TOTAL OF SECTION I, II, III AND IV) (250- CLOCK HOUR
PDS-17.5 (05/04) 4 MINIMU M)
PDS-17.5 (05/04) 5 PDS-17.5 (05/04) 6