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)