PROFESSIONAL MEMBERSHIPS If more than 4, combine multiples in 1 box. Organization Name Organization’s Focus/Mission Dates of Membership If more than 4, please list additional here. EMPLOYMENT--CURRENT Primary Employer Name with Employer Current Position or Employer Address City ZIP Type of Setting Academic Institution Community-Based Setting Government--Federal Government--Local, State Home Health Agency Long-term Care Facility/SNF Hospital Setting Military Non-profit Agency Private Industry Private Practice Facility School System Other (please specify): ____________________ Clients Served Please identify the populations served at this setting on this application is based.
VERIFICATION OF EMPLOYMENT/VOLUNTEER SERVICE An employment/volunteer verification form is required to provide verification of the required hours (see next page). Applicants may submit as many forms as needed to verify the required hours, and duplication of the form is acceptable if needed for more than one employer. Instructions for submitting Verification Form: Print the form and have employers(s) complete. Include the form as a scanned document as the first page(s) of either the application or evidence file. Tracking is up to applicants how to track the specifics of their service delivery. We ask only for the employment verification form(s) to be submitted, so be sure that whoever is verifying the information feels comfortable and ethical with whatever tracking system is used. Self-Employed--Because private practice on many different forms, applicants have varying ways in which to handle employment verification. Examples of who might verify the form include Administrator for a company/organization that contracted with the private practitioner for services Referral source Business partner or co-owner Accountant for the practice. If none of the options listed fit an applicant’s situation, and the applicant has an alternative source for verification to use, the applicant may forward that information for review and approval to prior to submitting an application.
Professional Development Goal 1 To which criterion does this goal apply (check 1)? Knowledge: Diagnostic Considerations Knowledge: Assessment Knowledge: Intervention Knowledge: Regulation and Payers Assessment: Performance Skills Intervention: Performance Skills Intervention: Critical Reasoning Psychosocial Critical Reasoning Ethical Practice Establishes Networks Advocating for Change Applicant’s Goal 1: Professional Development Goal 2 To criterion does this goal apply (check 1)? Knowledge: Diagnostic Considerations Knowledge: Assessment Knowledge: Intervention Knowledge: Regulation and Payers Assessment: Performance Skills Intervention: Performance Skills Intervention: Critical Reasoning Psychosocial Critical Reasoning Ethical Practice Establishes Networks Advocating for Change Applicant’s Goal 2: Professional Development Goal 3 To criterion does this goal apply (check 1)? Knowledge: Diagnostic Considerations Knowledge: Assessment Knowledge: Intervention Knowledge: Regulation and Payers Assessment: Performance Skills Intervention: Performance Skills Intervention: Critical Reasoning Psychosocial Critical Reasoning Ethical Practice Establishes Networks Advocating for Change Applicant’s Goal 3: