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DVS Initial Application Review
Applicant's Name
Reviewer's Name
Date of Review
Month
January
February
March
April
May
June
July
August
September
October
November
December
Month
/
Day
1
2
3
4
5
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31
Day
/
Year
Certification Type
Direct Service/Systems Advocacy
Prevention
Dual
Application
Has the Consent for Release of Information been signed?
Yes
No
Has the application been signed?
Yes
No
Has the applicant submitted verification of a Criminal Background Check?
Yes
No
Has the applicant signed the Professional Code of Ethics?
Yes
No
Evaluations
Have the following evaluations been received? Please check all that apply.
Supervisor
Coworker/colleague
Local Community Agency
Do any of the evaluations require follow up?
Yes
No
Comments on the evaluations (optional)
Has the applicant satisfactorily completed all questions in the Self-Evaluation?
Yes
No
Training and Education
Has the applicant completed at least 30 hours of training and education in Core Training categories (I through IV)?
Yes
No
Has the applicant completed 40 hours of training in Direct Service/Systems Advocacy Categories (V through IX)?
Yes
No
N/A
Has the applicant completed 40 hours of training in Prevention categories (X through XIII)?
Yes
No
N/A
Comments about the applicant's training and education (optional)
Mentoring
Has the applicant completed 12 mentoring sessions with a certified DVS?
Yes
No
Has the applicant provided sufficient justification for elective topics?
Yes
No
Comments on mentoring experience (optional)
Additional Comments
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Do you have any other comments or questions regarding this application?
Recommendation
The Certification Review Pane may, at its discretion, require an interview and/or additional references. I recommend the following for the above named applicant:
Certify
Request for more information
Request for an interview
Do not certify
If you have selected any option other than "Certify," please provide comments here.
