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DVS Recertification Application Review
Applicant's Name
Reviewer's Name
Date of Review
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Certification Type
Direct Service/Systems Advocacy
Prevention
Dual
Application
Has the Consent for Release of Information been signed?
Yes
No
Has the applicant signed the Professional Code of Ethics?
Yes
No
Has the application been signed?
Yes
No
Evaluation
Has at least one evaluation been submitted on behalf of the applicant?
Yes
No
Does the evaluation require follow up?
Yes
No
Comments on the evaluation (optional)
Training and Education
Has the applicant completed at least 24 hours of training and education since their last application was submitted?
Yes
No
Do the training activities cover at least three separate categories?
Yes
No
Comments about the applicant's training and education (optional)
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:
Recertify
Request for more information
Request for an interview
Do not certify
If you have selected any option other than "Recertify," please provide comments here.
