<p> 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)</p><p>EDUCATION AND TRAINING PROVIDER:</p><p>CPP 250-HOUR CERTIFICATE PROGRAM INFORMATION</p><p>SECTION I – KNOWLEDGE OF ALCOHOL AND SUBSTANCE ABUSE AT ALL AGE LEVELS AND AMONG PEOPLE OF DIVERSE BACKGROUNDS AND CULTURES (85 CLOCK HOURS)</p><p>NUMBER OF CLOCK HOURS</p><p>ATTACHED FOR PREVIOUSLY PENDING REVIEW AND TITLE OF COURSE/TRAINING APPROVED APPROVAL APPROVAL</p><p>TOTALS COLUMN TOTAL COLUMN TOTAL COLUMN TOTAL SECTION TOTAL</p><p>INFORMATION ON NEXT PAGE MUST BE COMPLETED</p><p>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)</p><p>EDUCATION AND TRAINING PROVIDER:</p><p>CPP 250-HOUR CERTIFICATE PROGRAM INFORMATION</p><p>SECTION II – PREVENTION SPECIFIC AND RELATED TO THE FIVE PERFORMANCE DOMAINS (AREAS OF PROFESSIONAL EXPERTISE) (60 CLOCK HOURS)</p><p>NUMBER OF CLOCK HOURS</p><p>ATTACHED FOR PREVIOUSLY PENDING REVIEW AND TITLE OF COURSE/TRAINING APPROVED APPROVAL APPROVAL</p><p>TOTALS COLUMN TOTAL COLUMN TOTAL COLUMN TOTAL SECTION TOTAL</p><p>INFORMATION ON NEXT PAGE MUST BE COMPLETED</p><p>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)</p><p>EDUCATION AND TRAINING PROVIDER:</p><p>CPP 250-HOUR CERTIFICATE PROGRAM INFORMATION</p><p>SECTION III – PROFESSIONAL DEVELOPMENT AND ETHICAL RESPONSIBILITIES (45 CLOCK HOURS, INCLUDING A MINIMUM OF 12 CLOCK HOURS FOCUSED ON INDIVIDUAL AND PROGRAM ETHICS)</p><p>NUMBER OF CLOCK HOURS</p><p>ATTACHED FOR PREVIOUSLY PENDING REVIEW AND TITLE OF COURSE/TRAINING APPROVED APPROVAL APPROVAL</p><p>TOTALS COLUMN TOTAL COLUMN TOTAL COLUMN TOTAL SECTION TOTAL</p><p>INFORMATION ON NEXT PAGE MUST BE COMPLETED</p><p>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)</p><p>EDUCATION AND TRAINING PROVIDER:</p><p>CPP 250-HOUR CERTIFICATE PROGRAM INFORMATION</p><p>SECTION IV – PREVENTION PRINCIPLES AND PRACTICES AND THE SERVICES CONTINUUM (60 CLOCK HOURS)</p><p>NUMBER OF CLOCK HOURS</p><p>ATTACHED FOR PREVIOUSLY PENDING REVIEW AND TITLE OF COURSE/TRAINING APPROVED APPROVAL APPROVAL</p><p>TOTALS COLUMN TOTAL COLUMN TOTAL COLUMN TOTAL SECTION TOTAL</p><p>CERTIFICATE PROGRAM TOTAL (SUM TOTAL OF SECTION I, II, III AND IV) (250- CLOCK HOUR</p><p>PDS-17.5 (05/04) 4 MINIMU M)</p><p>PDS-17.5 (05/04) 5 PDS-17.5 (05/04) 6</p>