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)

TITLE OF COURSE/TRAINING

NUMBER OF CLOCK HOURS

PREVIOUSLY APPROVED

PENDING APPROVAL

ATTACHED FOR REVIEW AND APPROVAL

TOTALS COLUMN TOTAL COLUMN TOTAL COLUMN TOTAL SECTION TOTAL

INFORMATION ON NEXT PAGE MUST BE COMPLETED

PDS-17.5-CPP (4/24/2020)

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)

TITLE OF COURSE/TRAINING

NUMBER OF CLOCK HOURS

PREVIOUSLY APPROVED

PENDING APPROVAL

ATTACHED FOR REVIEW AND APPROVAL

TOTALS COLUMN TOTAL COLUMN TOTAL COLUMN TOTAL SECTION TOTAL

INFORMATION ON NEXT PAGE MUST BE COMPLETED

PDS-17.5-CPP (4/24/2020)

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)

TITLE OF COURSE/TRAINING

NUMBER OF CLOCK HOURS

PREVIOUSLY APPROVED

PENDING APPROVAL

ATTACHED FOR REVIEW AND APPROVAL

TOTALS COLUMN TOTAL COLUMN TOTAL COLUMN TOTAL SECTION TOTAL

INFORMATION ON NEXT PAGE MUST BE COMPLETED

PDS-17.5-CPP (4/24/2020)

PDS-17.5-CPP (4/24/2020)

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)

TITLE OF COURSE/TRAINING

NUMBER OF CLOCK HOURS

PREVIOUSLY APPROVED

PENDING APPROVAL

ATTACHED FOR REVIEW AND 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 MINIMUM)