Read 08-NCI-MAN-005:03-NCI-MAN-020 text version

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3315-H North 124th Street Brookfield, WI 53005 USA 1-877-877-5390 1-888-758-6048 TTY (Deaf, hard of hearing, or speech impaired) Fax 1-262-783-5906 · Email [email protected]

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Nonviolent Crisis Intervention ® Training Roster

Please print legibly in pen. Clear penmanship assures the proper documentation of your training hours. For instructions on how to fill out this roster, please refer to your Instructor Manual, visit www.iancici.org, or call 1-877-877-5390.

STEP 1: PARTICIPANT INFORMATION Please print or type each attendee name on reverse side and enter total number of participants that successfully completed training within this box. (40 maximum) STEP 2: COURSE INFORMATION Please indicate first and last dates of training, number of hours taught, and which training option was conducted. First Date of Training Last Date of Training Total Hours Taught m m m m d d y y d d y y Initial Nonviolent Crisis Intervention ® Training Units I through VII and Unit X: Minimum 6 Hours Units I through X (Entire Course): Minimum 8 hours

Formal Refresher Program: Minimum 3 Hours (Please select which option was taught.) Initial Nonviolent Crisis Intervention ® Participant Workbook Key Point Refresher Workbook Master Associate Level Customized Refresher Personal Prevention PlanSM Video/DVD Based Refresher (Please indicate title to the right.)_________________________________ Formal Advanced Refresher Program: (Follow Advanced Instructor Excellence Renewal Program Materials for Minimum Length and Standards.) Applied Physical Training SM Autism Spectrum Disorders: Applications of Nonviolent Crisis Intervention ® Training Enhancing Verbal Skills: Applications of Life Space Crisis Intervention SM STEP 3: INSTRUCTOR INFORMATION Please print the Instructor information using legible block characters in the ID# boxes (enter last 7 characters of ID#). Enter the number of hours present and include signatures for each Instructor.

Instructor Name

No more than three Instructors per training.

ID#

04-PE04-PE04-PE-

Hours Present

Signature:

Certified Instructor(s) need to sign to certify that each participant on the roster has successfully completed Nonviolent Crisis Intervention ® training in accordance with applicable standards.

Blue cards will be mailed to this address.

STEP 4: ADDRESS INFORMATION Please print the mailing information. Please check box(es) that apply. This is my: Home address Work address

Mr./Mrs./Miss/Ms. Title Facility Address City State/Province Email First Name

A new preferred mailing address

Last Name

Zip/Postal Code

Country

Phone (Area Code) (Phone Number)

(Extension) Fax (Area Code)

(Fax Number)

(Extension)

STEP 5: SUBMIT THE ROSTER AND ORIGINAL POST-TESTS Submit original post-tests in the same order as the names appear on the reverse side within 30 days of the training. Copies of the roster and post-tests should be retained for your records. Notes: ________________________________________________________________________________________________

_________________________________________________________________________________________________ ____ _

__________________________________________________________________________________________________________

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© 2008 Crisis Prevention Institute, Inc

YROST01 07-NCI-FOR-021 03/08

Roster

1. Please complete both sides of this form. 2. Please submit original post-tests in the order the names appear below. 3. Please legibly print or type all participant names.

1. __________________________________________ 2. __________________________________________ 3. __________________________________________ 4. __________________________________________ 5. __________________________________________ 6. __________________________________________ 7. __________________________________________ 8. __________________________________________ 9. __________________________________________ 10. ________________________________________ 11. ________________________________________ 12. ________________________________________ 13. ________________________________________ 14. ________________________________________ 15. ________________________________________ 16. ________________________________________ 17. ________________________________________ 18. ________________________________________ 19. ________________________________________ 20. ________________________________________

Pass Fail

Pass Fail

21. ________________________________________ 22. ________________________________________ 23. ________________________________________ 24. ________________________________________ 25. ________________________________________ 26. ________________________________________ 27. ________________________________________ 28. ________________________________________ 29. ________________________________________ 30. ________________________________________ 31. ________________________________________ 32. ________________________________________ 33. ________________________________________ 34. ________________________________________ 35. ________________________________________ 36. ________________________________________ 37. ________________________________________ 38. ________________________________________ 39. ________________________________________ 40. ________________________________________

Information

08-NCI-MAN-005:03-NCI-MAN-020

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08-NCI-MAN-005:03-NCI-MAN-020