Registration 2013 final

  IA-­‐APSE  Employment  Summit     Employment  First  in  Iowa:   When  Everybody  Works,   Everybody  Wins!      ...

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IA-­‐APSE  Employment  Summit    

Employment  First  in  Iowa:   When  Everybody  Works,   Everybody  Wins!    

 

Sessions  for  Executives,  Supervisors,   Policy  Makers,  People  with  Disabilities,   Job  Developers,  Job  Coaches,  Family   Members  

October  9th  and  10th,  2013   Ramada  Tropics   Des  Moines,  IA    

Employment First Mission: To change beliefs, practices, systems and funding so that employment in the general workforce is the first and preferred outcome in the provision of publicly funded services for all working age Iowans with disabilities, regardless of level of disability.

 

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Join us for the Iowa-APSE Annual Employment Summit This year the Iowa-APSE Summit brings together an allstar line-up of national and local experts in the area of integrated employment. The Summit will start at 1:00 pm Wednesday October 9th with our own David Mitchell of Iowa Vocational Rehabilitation Services and Rick Shults of Mental Health and Disability Services providing us with their vision of Employment First in Iowa. Cary Griffin of Griffin-Hammis and Associates will follow with a rousing, thought-provoking and sure-to-be-entertaining keynote. The Summit offers three tracks this year: Advocacy and Policy Leadership/Supervision Direct Support There will also be an entire day devoted to skill building for direct service personnel in the area of Customized Employment with Michael Callahan of Marc Gold and Associates, one of the leading experts of Customized Employment. Iowa-APSE is proud to have Margaret Lee Thompson a highly acclaimed parent advocate as part of the Summit lineup. After meeting with a core group of parents during the first concurrent session period on Thursday, she will be hosting the session on advocacy that will continue the rest of the day. Prior to the Summit on the morning of the 9th, IA-APSE is hosting the Certified Employment Support Professional Exam. After successfully completing it, employment personnel earn the title of Certified Employment Support Professional, a national recognition. This requires a separate registration and fee. The application is contained on pages 11-16 of this information. Be sure to plan to attend the Welcome Reception held 4:30-6:00 Wednesday evening. It offers a great way to get reacquainted with old friends, make new ones and just have some fun.

Come, join us! Get energized, rejuvenated and learn from each other!

Registration Due September 25th CEU’s and CRC’s have been applied for  

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Key Note Day One Speaker CARY GRIFFIN Senior Partner at Griffin Hammis Associates Griffin-Hammis Associates is a full service consultancy specializing in building communities of economic cooperation, creating high performance organizations, and focusing on disability and employment. He is also Co-Director of the U.S. Dept. of Labor’s National Self Employment Technical Assistance, Resources and Training project with Virginia Commonwealth University, and is a Subject Matter Expert hired by the U.S. Dept. of Labor to help implement Employment First nationally. Cary provides training to administrative and direct service level professionals in the rehabilitation field; consultation to businesses and rehabilitation agencies regarding the employment of individuals with significant disabilities; field-initiated research & demonstration; family & consumer consultation; resource development; and organizational development. Cary is author of the book Working Better, Working Smarter, and co-author of the books Making Self Employment Work for People with Disabilities (currently under revision), and the first book on Customized Employment, The Job Developer’s Handbook: Practical Tactics for Customized Employment. Current projects include development and management of a statewide Rural Florida Customized Employment initiative, a statewide disability selfemployment project in Kansas, and a similar project in Appalachia, developing the strategic plan for British Columbia’s CE and Employment First program, several state Money Follows the Person and Medicaid Infrastructure Grant initiatives (Rhode Island, Minnesota, Iowa, et al.), and inner city Customized Employment projects (Philadelphia, Los Angeles, et al.). Cary is currently writing a new book on career planning tentatively titled: Your Vocational Themes: Going Where The Career Make Sense.

Topic Employment First: If You Aren’t Living On The Edge, You’re Taking Up Too Much Space The national conversation about Employment First is revitalizing policy and practice. Some worry that customized community employment will be too expensive and difficult for everyone, even though we already managed to erect a parallel system of some 5,000 sheltered programs, our own transit systems, and housing that mimics but often precludes real life in our communities. This session uses humor, national examples, and strong evidence to illuminate: critical economic leverage points for success; the unlimited ways to make a living in this world, new skills we each need for customizing employment; augmenting self-advocacy & family power; how Bridging & Bonding Social Capital help make sheltered/segregated work models irrelevant; why running parallel systems is too expensive and unproductive to continue; that hiring someone remains both a personal and an economic decision for employers; and why fear keeps us running the same old expensive programs.

Cary also serves as Deputy Director and Board Chair of the Center for Social Capital, a non-profit affiliate of Griffin-Hammis Associates.

 

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Key Note Day Two KATHLEEN MARTINEZ Assistant Secretary for Disability Employment Policy Kathleen Martinez was nominated by President Barack Obama to be the third Assistant Secretary for Disability Employment Policy and was confirmed by the U.S. Senate on June 25, 2009. As head of the U.S. Department of Labor’s Office of Disability Employment Policy (ODEP), Ms. Martinez advises the Secretary of Labor and works with all DOL agencies to lead a comprehensive and coordinated national policy regarding the employment of people with disabilities. Blind since birth, Ms. Martinez comes to ODEP with a background as an internationally recognized disability rights leader specializing in employment, asset building, independent living, international development, diversity and gender issues.

Because We are EQUAL to the Task

A critical priority for the U.S. Department of Labor, Office of Disability Employment Policy (ODEP), is to invest in systems change efforts that result in increased integrated employment opportunities for individuals with significant disabilities. This priority reflects growing support for a national movement called Employment First, a national movement in which publicly-financed systems are urged to align policies, regulatory guidance, and reimbursement structures to commit to integrated employment as the priority option for services. In 2012 ODEP launched the Employment First State Leadership Mentor Program (EFSLMP), a cross-disability and cross-systems change initiative. Iowa has been part of this initiative and has received mentoring, intensive technical assistance and training along with two other states as they transform their delivery systems to an Employment First approach.

She was appointed Executive Director of the World Institute on Disability (WID), based in Oakland, California, in 2005. Ms. Martinez directed Proyecto Visión, WID's National Technical Assistance Center to increase employment opportunities for Latinos with disabilities in the United States, and Access to Assets, an asset-building project to help reduce poverty among people with disabilities. At WID, she also led the team that produced the on her personal acclaimed international webzine DisabilityWorld Based experiences, AS Martinez will (www.disabilityworld.org) in English and Spanish. share her perspective on what it In 2007 she was appointed a member of the board of the U.S. Institute of Peace, a Congressionally-created agency dedicated to research and projects in conflict management. In 2005, Secretary of State Condoleezza Rice appointed her as one of eight public members of the newly-established State Department advisory committee on disability and foreign policy. In 2002 she was appointed by President Bush as one of 15 members of the National Council on Disability, an independent federal agency advising the President and Congress on disability policy.

 

takes to transform our thinking as a society and as systems to support individuals with disabilities. Martinez will also provide her reflections on ODEP’s investments in the EFSLMP generally and in the state of Iowa specifically. Finally, Martinez will challenge the audience to rise to the occasion in terms of being innovative, dedicated, and collaborative in helping the state of Iowa in achieving its ambitious systems transformation goals.

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Other Featured Speakers for the 2013 IA-APSE Annual Employment Forum In Alphabetical Order Michael Callahan: Michael has consulted throughout the US, Canada and Europe in the area of employment and transition for the past thirty years. He has worked with Marc Gold & Associates (MG&A) for 34 years, and has served as president of the organization since Marc Gold’s death in 1982. MG&A is a network of consultants that provides training and technical assistance to systems, agencies and families interested in insuring the complete community participation of persons with significant disabilities. He is a co-author of two popular "how-to" books on employment for persons with significant disabilities, Getting Employed, Staying Employed and Keys to the Work Place. He has written numerous articles, chapters, manuals and curriculums pertaining to employment. He has a master’s degree in special education and did doctoral work at Syracuse University in vocational rehabilitation. He is currently a national board member for TASH and was a founding board member of APSE. Michael’s current work focuses on Customized Employment and Discovery as an extension of the concept of supported employment for persons with significant disabilities. Nancy Gurney, M.A.: Nancy is the President and CEO of Opportunity Services in Minneapolis, Minnesota. She is responsible for leadership, innovation and performance for multiple state services including Minnesota, Florida and Wisconsin. Services include Vocational Rehabilitation, Medicaid Waiver, Extended Employment, Day Training & Habilitation, Ticket to Work Employment Network, and Project Search. Services are provided in communities for a wide range of persons with disabilities including developmental disabilities, Brain Injury, CADI, hearing impaired and mental health. Opportunity Services has an annual budget of eight million with services to 1,000 persons annually. She has experience in transformation of sheltered workshops, day services to community employment and diversion from sheltered work, TANF reform employment demonstration, and TTW employment network. Her education includes expertise in education, psychology, business, leadership and Baldrige Quality Performance measurements. She serves the ODEP as a subject matter expert for Employment First. Geery Howe, M.A.: Geery is a consultant, executive coach and trainer in the fields of leadership, strategic planning and organizational change. Since the late 1980’s, Geery has worked extensively with thousands of executives from large corporations to small non-profits, from colleges and universities to public school districts, from hospitals to organizations that serve people with disabilities. Through stories, research, lessons learned, and practical advice based on working with people, teams and organizations through many difficult challenges, Geery will help participants understand how successful organizational change takes place and how effective leaders move people through the difficult periods to a new level of performance. Serena Lowe is the Senior Policy Adviser at the Office of Disability Employment Policy (ODEP) within the U.S. Department of Labor as a Senior Policy Adviser. In this capacity, Serena is responsible for a number of Federal policy initiatives focused on promoting the socioeconomic advancement of citizens with disabilities, including the Department’s Employment First State Leadership Mentoring Program. Through this initiative, ODEP provides access to mentoring and indepth training and technical assistance to support states’ efforts to align public policy and funding toward an emphasis on integrated employment as the preferred outcome for citizens with significant disabilities.  

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Prior to joining ODEP, for the past fifteen years, Serena worked in both government and the private sector as a consultant to over 35 national corporate and not-for-profit entities in the areas of public policy, advocacy, coalition building, strategic & commercial planning, and organizational development. Most recently, Serena started AnereS Strategies LLC in 2009, a consulting enterprise focused on developing innovative strategies for pursuing high-impact public policy reforms predominately aimed at promoting the economic empowerment of low-income working families, citizens with disabilities, and other at-risk populations. During this time, Serena also served as the Executive Director of the Collaboration to Promote Self-Determination (CPSD), a dynamic coalition of fifteen national disability organizations committed to promoting high-impact public policy reform aimed at ensuring that citizens living with significant disabilities have access to opportunities for meaningful engagement in the areas of education, employment, independent living, and community engagement. Earlier in her career, Serena served as a senior policy advisor to a global pharmaceutical company and two Members of the U.S. House of Representatives. Serena earned a B.A. in International & Public Affairs from Westminster College (Fulton, MO) in 1997; an M.P.H. in International Health Policy and M.A. in International Development Policy from George Washington University (Washington D.C.) in 2002; and is currently pursuing a PhD in public administration at American University’s School of Public Affairs in Washington, D.C. Dr. Laura A. Owens: Dr. Owens has been the Executive Director of APSE (the Association of People Supporting EmploymentFirst), a national organization focusing on the advancement of integrated employment for citizens with disabilities based in Washington, DC since October 2008. (www.apse.org). She is also an Associate Professor at the University of Wisconsin-Milwaukee in the department of Exceptional Education where she teaches courses focusing on high school inclusion and transition from school to work. Dr. Owens is the Director of Creative Employment Opportunities, Inc. (CEO), an employment agency for individuals with disabilities in Milwaukee, Wisconsin (www.ceomke.com) which she founded in 1991. She is an internationally known speaker having presented to business organizations, schools and conferences in Ireland, Croatia, the Czech Republic, Chile and other countries. Laura earned her M.S. degree in special education from the University of Wisconsin - Milwaukee and her Ph.D. from the University of Wisconsin - Madison. Margaret-Lee Thompson: Margaret Lee has recently retired as the Coordinator of the King County Parent Coalition for Developmental Disabilities, which is a program of The Arc of King County. The Parent Coalition, formed by Margaret-Lee in 1990, is active in systems advocacy with the state legislature. The King County Parent Coalition was the first in the state of Washington. There are now Parent Coalitions established or forming in 18 counties in Washington State. Margaret-Lee and her husband are the parents of a son with Down Syndrome, who passed away at the age of 36 years. He worked at Microsoft in the Supply Center and Mail Room for over fourteen years. While raising their three children, she worked as a volunteer advocate in four states (Washington, Texas, Wisconsin and California) for twenty years. She is a graduate of the University of Washington and was a teaching assistant and research technician in the Department of Botany.

 

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Conference At A Glance Wednesday,  October  9,  2013   8:00-12:00

Certified Employment Support Professional Examination (Separate Registration)

12:00-1:00

Conference Registration

1:00-2:30

Dr. SueAnn Morrow, President IA-APSE Welcome Keynote Addresses: David Mitchell, Administrator, Iowa Vocational Rehabilitation Services: The Vision of Employment First in Iowa from IVRS’s Perspective Rick Shults, Administrator, Mental Health and Disability Services: The Vision of Employment First from MHDS’s Perspective Cary Griffin, Griffin-Hammis and Associates: Employment First: If You Aren’t Living on the Edge, You Are Taking Up Too Much Space  

2:30-2:45

Break with Snacks

2:45 to 4:15

Concurrent Sessions: Dr Laura Owens, Executive Director of APSE Employment First: The Modernization of Employment Policy Cary Griffin, Griffin-Hammis and Associates: The Contractions of Leadership: Ten (Maybe 9, Could be 10) Considerations for Leader at All Levels Panel of CRP Personnel from the EFSLMP/ICIE Pilot Projects: Customized Employment: Making It Happen in Iowa  

4:30-6:00

Iowa APSE Welcome Reception and Annual Meeting

Thursday,  October  10,  2013   7:15 am to 8:15 am

Buffet Breakfast from Restaurant (Need a Ticket)

8:30 to 10:00

Concurrent Sessions: Panel of Successful Individuals with Disabilities: My Road to Success Michael Callahan, Marc Gold and Associates Job Development for Customized Employment: Connecting Job Development and Job Coaching With a Task-Focused Strategy (This is a daylong workshop for specific skill building.) To Be Determined: DC Update: Promoting Disability Employment in a Challenging Fiscal and Political Environment

10:00 to 10:15

Break with Snacks

10:15 to 11:45

LeAnn Moskowitz, IME; Lin Nibbelink, MHDS; Lee Ann Russo, IVRS: Employment Services: What We’ve Been Doing and Where We Are Going

 

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Serena Lowe, ODEP:     Rising  to  the  Occasion  through  Transformational  Leadership:    A  National  Review   Employment  First  State  Systems  Change  Efforts Margaret Lee Thompson, Parent Advocate:  It  Takes  A  Village  for  Effective  Advocacy   Michael Callahan: Continued   12:00 to 1:30

Christina Moffett, Owner Crème Cupcakes: Customized Employment: It’s Working in Iowa Assistant Secretary, ODEP, Kathleen Martinez: Because We are EQUAL to the Task

1:30 to 1:45

Break  

1:45 to 3:15

Margaret Lee Thompson: Continued Michael Callahan: Continued Gerry Howe, Morning Star Associates: When Change is the Only Constant Nancy Gurney, Opportunity Services: Transformation: Page 2

Conference Logistics Location:

Ramada Tropics 5000 Merle Hay Rd. Des Moines, IA 50322 Exit 131 off I-80

Contact:

A block of rooms has been reserved at a special rate of $55.00 plus tax. Call the hotel direct and ask for the IA-APSE room block. Rooms will be held until September 17th. 515-278-0271

Dates:

Begins 1:00 Wednesday October 9; ends 3:15 Thursday October 10

Questions:

Dr. SueAnn Morrow, President 319-430-8710 Ashlea Lantz, President-Elect 515-259-8115

CEU’s and CRC’s have been applied for.  

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Iowa APSE is partnering with national APSE to offer the first national certification program for   Employment Support Professionals on October 9, 2013 From 8:00 to noon Ramada Tropics| 5000 Merle Hay Rd. |Salons A & B Des Moines, Iowa Now job coaches, job developers, transition employment specialists, job placement personnel, and employment specialists/consultants can earn the designation of Certified Employment Support Professionals (CESP) by passing the national CESP examination. The fee to take the exam is $159.00 Applications must be received by September 20th and applications will not be processed after this date. Seats are limited to 30 and will be filled on a first come-first served basis. Benefits of Certification for Provider Agencies and Employment Support Professionals (ESPs): CESP certification provides national guidelines to validate and support the training currently provided by university, community college, and other technical training centers across the country. CESP certification, unlike state level licensure, also enables portability across states and regions. For Employment Support Professionals: CESP certification shows colleagues, supervisors and the individuals you serve that you completed a rigorous process to earn your national professional credential. CESP certification opens the door to:  Improved professional advancement & job opportunities  Increased income opportunities  Enhanced credibility with employers How do I prepare to take the CESP examination? The exam is based on the results of a national Role Delineation Study and the resulting content outline. The exam includes questions from each content area in the percentage ranges noted in the test blueprint. Candidates should carefully review the content outline, also known as the test blue print as they prepare for the exam. Download the test blue print at www.apse.org/certification To register for the CESP exam in Iowa mail the registration and fee for $159.00 to: APSE/CESP/IA Exam, 416 Hungerford Drive, Suite 418, Rockville, MD 20850 301.279.0075 Fax | 301.279.0060 Phone Questions? Please contact: Jennifer Polkes, CESP Program Coordinator at [email protected] or Patricia K. Keul, ESPCC Director at [email protected] or 704-534-1943

This is not part of the Summit program and requires a separate registration and fee.  

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Registration  Form

Registrations Due September 25 th  

 

Names:  (Groups  of  3  or  more  receive  a  special  registration  rate  –  see  below)   1. _________________________________________________________________________________________    

 

2. _________________________________________________________________________________________   3. _________________________________________________________________________________________   4. _________________________________________________________________________________________   5. _________________________________________________________________________________________   Organization:  ________________________________________________________________________________   Address:  _____________________________________________________________________________________   Phone:  ________________________  Email:    ______________________________________________________     Special  Diet  Requests:  ______________________________________________________________________   Reasonable  Accommodations  Requests:  __________________________________________________   ________________________________________________________________________________________________   If  an  interpreter  or  materials  in  Braille  are  needed,  please  notify  us  by  August  31st.   Registration  includes  breakfast  and  lunch  on  Thursday,  break  goodies  both  days     and  hors  d’oeuvres  at  the  Wednesday  evening  reception.   #  

Type  of  Registration  

Unit  Price  

Total  

 

Self-­‐Advocate,  family  member  or  self-­‐advocate  support  staff  

   $75.00  

 

 

Group  registration  for  3  or  more  (members  and  non-­‐members)  

$125.00  

 

 

APSE  Member  Registration                                      Member  #  -­‐    

$150.00  

 

 

Non-­‐member  Registration  

$175.00  

 

  Total  Enclosed:    $_______________________   Iowa-­‐APSE  does  not  currently  have  the  capacity  to  accept  on-­‐line  or  credit  card  payments.   For  planning  purposes,  please  let  us  know  if  you  plan  to  attend:    Circle  One   Both  Days  

 

                     

Days  One  Only                                                

     Day  Two  Only    

  Please  send  completed  registrations  and  payment  to:   IA-­‐APSE,  c/o  Van  Buren  Job  Opportunities,  308  Mulberry  St.,  Keosauqua,  IA  52565  

Thank  you!      

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CESP  Exam  Application,  2013  

   

Certified Employment Support Professional Exam Application          

The following pages are the Application for those interested in taking the Certified Employment Support Professional Exam. This is not part of the IA-ASPE Summit Program and requires a separate application and fee.

 

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CESP  Exam  Application,  2013  

 

CESP Exam Application October 9, 2013 Ramada Tropics| 5000 Merle Hay Rd Salon A & B Des Moines, Iowa 50322 Please print clearly and neatly. Fill out all sections of the application. Incomplete or illegible applications will not be processed. Confirmations and other important exam information will be sent to you via email. Please ensure your email address is correct. All applications must be received at APSE before September 20th at 5pm. The exam room is limited to 30 test takers so registration will close on September 20 or earlier if 30 eligible test takers apply before the closure date. Mail the application and fees to: APSE/CESP/IA Exam 416 Hungerford Drive, Suite 418 Rockville, MD, 20850

SECTION  1.  Candidate  Information  (print  clearly)   Last  Name  

First  Name  

Middle  Initial/Name  

Street  Address/PO  Box   City  

State  

Home  Phone  Number  (including  area  code)  

Email  Address  (required)*  

Credentials  

Employer/Company  

Job  Title  

Work  Phone  Number  

Zip  

Address   City  

State  



 

 

Zip  

Please  provide  the  e-­‐mail  address  where  your  exam  results  may  be  sent  to  you  and  maintain  your   privacy-­‐  Usually  home  e-­‐mail  is  preferred.  The  name  and  address  listed  above  must  match  the   name  and  address  on  your  government-­‐issued  photo  identification  required  for  entrance  to  the   exam.  

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CESP  Exam  Application,  2013  

I  am:       a  new  applicant  (not  currently  certified)                applying  to  retest,  date  of  last  exam:      

 

 Exam Date October 9, 2013: Photo ID required for check- in.  8:00 am to noon  Mail your CESP exam application and fee $159.00 to: APSE/CESP/IA Exam 416 Hungerford Drive, Suite 418 Rockville, MD, 20850

Exam Location: CESP Exam October 9, 2013 Ramada Tropics| 5000 Merle Hay |Salons A & B Des Moines, Iowa 50322  I am including a Request for Accommodations. Candidates requesting special accommodations must submit the Request for Accommodations form at least 2 weeks prior to the examination date with appropriate documentation as described in the handbook. Accommodation requests are due by: September 20, 2013 SECTION  2.  Eligibility   Education  (please  list  highest  level  of  education  completed  below):   School:  

Degree:  

Date  Completed:  

School:  

Degree:  

Date  Completed:  

Length  of  paid  ESP  work  experience   (see  definition  below):  

Years:  

Months:  

Length  of  internship(s):  

Internship  #1:  

Internship  #2:  

Course  Name:  

Date  Completed:  

Total  Hours:  

Course  Name:  

Date  Completed:  

Total  Hours:  

Experience:  

Training:  

 

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CESP  Exam  Application,  2013   Code  of  Conduct:     I  hereby  attest  that  I  have  read  and  understand  the  ESPCC  Code  of  Conduct  and  agree  to  abide  by  the  Code  of  Conduct.    Required  Signature:  

Date:  

Work  experience  is  defined  as  at  least  20  hours  per  week  of  paid  ESP  related  work.  Work  completed  as  part  of  an  internship,   practicum,  or  other  on-­‐the-­‐job  training  may  be  counted  up  to  the  limits  noted  above.  Work  experience  includes  employment  as  a   direct  employment  services  professional,  provision  of  direct  employment  services  as  an  agency/company  employee,  and/or   managerial  or  supervisory  work  in  employment  services.  Experience  in  school-­‐to-­‐work  transition  environments  providing   employment  services  also  qualifies  as  acceptable  work  experience.     Training  is  defined  as  an  internship  or  practicum  of  at  least  2  months  in  length  and/or  successful  completion  of  an  intensive   training  course  that  includes  at  least  32  hours  of  ESP  related  course  work.  The  content  for  acceptable  training  courses  must  be   directly  related  to  the  CESP  content  outline.  Acceptable  training  content  is  related  to  supported  and  customized  employment  as   well  as  training  relevant  to  providing  employment  and  community  based  supports  to  people  with  disabilities.  Examples  of   acceptable  training  content  includes:  specialized  training  to  work  with  specific  disability  groups  (i.e.  autism  or  mental  illness),   training  on  small  businesses  development,  American  with  Disabilities  Act  (ADA)  training,  benefits  counseling,  and  strategies  for   job  development.    Training  related  to  segregated  employment  services  or  services  that  are  not  widely  considered  to  be  best   practices  will  not  be  accepted.  

  SECTION  3.  Attestation   I  have  read  and  understand  the  CESP  Certification  Handbook  and  agree  to  abide  by  the  policies  of  the   ESPCC,  including  confidentiality  and  disciplinary  rules.  I  understand  that  the  information  I  provide  to  ESPCC   may  be  audited  to  verify  my  eligibility.  I  authorize  ESPCC  to  make  any  necessary  inquiries  to  verify  my   eligibility.     I  understand  that  submission  of  false  or  misleading  information  at  any  time  may  be  cause  for  withdrawal  or   revocation  of  this  application  and/or  certification  without  refund  of  any  fees.   I  certify  that  the  information  contained  in  this  application  is  true,  complete,  and  correct  to  the  best  of  my   knowledge.      Required  Signature  

Date  

Request for Accommodations Form ESPCC will provide reasonable accommodations for exam candidates with disabilities that are covered under the Americans with Disabilities Act (ADA). Candidates requesting special accommodations must submit the Request for Accommodations Form at least 2 weeks prior to the exam date accompanied by appropriate documentation as described in the CESP Certification Handbook. ESPCC reserves the right to review any request for accommodations and have requests considered by its own experts to ensure an appropriate level of accommodations and protect the integrity of the examination and the certification.

 

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CESP  Exam  Application,  2013  

Last  Name  

First  Name  

Middle  Initial/Name  

Street  Address/PO  Box   City  

State  

Zip  

Home  Phone  Number  (including  area  code)  

Email  Address  (required)  

Special  Testing  Accommodations   I  request  special  accommodations  as  follows  (check  all  that  apply):      

Special  seating  or  other  physical  accommodation   Extended  exam  time   Separate  exam  room   Other  (please  describe):            

Signature  

 

 

 

 

 

 

Date  

Professional  Documentation   Professional  evaluation  must  have  been  made  no  earlier  than  3  years  prior  to  application   I  have  evaluated              

   

      Professional  title  

      Candidate  name    

 

   

 on  ____  /  ____  /  _____  in  my  capacity  as  a                        date  

.    I  have  been  informed  of  the  nature  of  the  examination  to    

be  administered.  It  is  my  opinion  that  because  of  this  candidate’s  disability,  as  described  below,  he/she   should  receive  the  special  testing  accommodations  requested  above.   Description  of  disability  (please  attach  any  supporting  documentation):    

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If  extra  exam  time  is  recommended,  please  specify  the  amount  of  time  requested  (e.g.  1  extra  hour):      

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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CESP  Exam  Application,  2013  

Professional’s  Name  

Credentials  

Address   City  

State  

Professional  License  Number  &  State  of  Issue  

Email  Address  (required)  

Signature  

Date  

Zip  

 

 

 

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