rIDesILaytags2dI1DSHS10_21010210052001052003Children's Administration!Staff Statement of Qualifications td    4  Pf0f  *>2d6 &,28>DJPV\bhntz6 (P9serdict begin /11x176NSubmit t b6}{statusdict /setpageparamsHHH@RG(HH@d'`H46464Tv exch scale pop pop xl}bdf /o6Z-1 rolN `8< @fffffff@/` ` ` "BgHn/. Hn0<N j@(#0" nC"" nC""BgHn.1&@XXjj2VXXd'ʄ[R$ od `/&6 PBse movV "  ҆HMV " propalis *$102100520010520031Children's AdministrationDSHS10_210-@!Staff Statement of Qualifications0031 Children's AdministrationDSHS10_210-@! J-1 rol\ t  Signature `VersionGraphics <TiffList`TPageList ZHeader`؀` FieldList`؀l LayoutProps Blue Keys f Form Info$ConvertDataVers~ DesPathInfox DC ExtList6DC List oveto}bdf/rm{it rmovet6 f76069503821609045Ver6f~@@ 6xthis|҅|҅| pr6 HTdsInformed Quadra Server0z>t ICHILDREN'S ADMINISTRATION DOMESTIC VIOLENCE PERPETRATOR TREATMENT PROGRAM .T .T  .T,Arial (>CHILDREN'S ADMINISTRATION (G/DOMESTIC VIOLENCE PERPETRATOR TREATMENT PROGRAM/ / MSTATEMENT OF QUALIFICATIONS FOR STAFF DSHS 10-210 (REV. 05/2001) AC 05/2003)  K K .T  K,Arial (*&STATEMENT OF QUALIFICATIONS FOR STAFF (*'DSHS 10-210 (REV. 05/2001) AC 05/2003)  P !STAFF STATEMENT OF QUALIFICATIONS    #@  l e!# 1. PROGRAM NAMEPlE PEl  K PlE,Arial (`*1. PROGRAM NAME/P!/# Page 1 of 4 &   3.  B B PlE B,Arial (*3.``#` A Have you ever been convicted of a crime involving moral turpitude? Have you ever been convicted of a crime involving violence? Have you ever been charged or received a deferred sentence for a crime involving violence, moral, or sexual issues? If the answer to questions 4a, b, or c is yes, explain on page 4. Have you attached a copy of your WA State Patrol criminal history background check? Have you ever been charged with a professional ethics violation? If the answer to question 5 is yes, explain on page 4. Have you ever been a party to a civil proceeding involving domestic violence? If the answer to question 6 is yes, explain on page 4. Have you attached a copy of a certificate signifying that you are a registered counselor or licensed mental health professional through the Department of Health?    =      f    7@ 7@ B 7@,Arial (ACHave you ever been convicted of a crime involving moral turpitude? ( ATrainee. Employee has not completed at least 250 hours of supervised direct treatment contact with perpetrators and domestic violence victim advocacy services. (Washington Administrative Code (WAC 388-60-0335))  q  t    @0 l    @  @Staff. Employee meets all requirements cited in WAC 388-60-0315.  *<  P@0 l    0@@ Supervisor. Employee is qualified to supervise direct treatment staff members and meets all requirements cited in WAC 388-60-0365.  $$: $: hE :,Arial (EGSupervisor. Employee is qualified to supervise direct treatment staff (E(@@ @ "     @BDFHJmnopdiqrst_!"u҆H֬֬҆H֬֬֬֬֬*֩ՇՇ֬֬֬֬֬֬֬֬֬֬֬֬֬֬֬֬֬֬֬֬֬֬֬֬֬֬֬֬( propalis propalisN propalisH propalisB porpsila porpsila*<EDataHelmnopq    !"@ABCDEFGHIJKLMPQRS^4_4`4a4b4c-d-e-f-g-h-i-j-k-l-mnopqrstuFALSE`<;\,(;\ @ `<;\;\,l;\ @ H(;\H;\ @tPB ;\;\,@;\ on`<;\,p;\@A`<;\;\,,;\BC`<;\;\,8;\D!E`<;\;\,(;\FHG`<;\;\,;\HuI`<;\;\,;xJ"KtPB ;\,@`;\qp`<;\,;\m n`<;\d;\no`<;\;\,P;\op`<;\;\,;\pPqF;\VBn8}R8} 8}(x6x6~Bx6161Your end date must be later than your start date.cd@F;\;\@VB~6T6*6(66~B6161Your end date must be later than your start date.hi@`<;\;\,8;\qrH(;\;\rs`<;\;\,;\sltH(;\;\tcF;\VB:6,66(r6r6~Br6161Your end date must be later than your start date.^_@tPB ;\,;\@ӈ,B@tPB ;\,@d;\DBtPB ;\,@`;\!FDt SUPERVISOR`l/<e / @@X   @@@@@@ @@@@@~*A"*A"*hT~*T~hIT~~iI  \I T~~z! RxIiITZxI~wIZ{IdDz! ɫD֫D01bD6OR„@@@@ _ l@@ XD6@@ @@ XD6@@@@n n@@ XD6@@RbD6OR@@X D6   L  5"U "5U )I 5"U,Arial e following.@ p Yes  qS @"@#P No  qS  0#@#Button19=L P#P#   a 0 !Button19u= P     a `$`$C   EDUCATION (continued)   qSs   P , 9. Do you have a master's or higher degree?    5"U ,Arial (!,9. Do you have a master's or higher degree?` $  @PP a# "VICTIM ADVOCACY EMERGENCY SERVICES"` @@@/-npA DESCRIBE EXPERIENCEILH @@@nA LOCATIONLI @@@@nA 0 FROM: MONTH/YEARIL@ @ $@@@0.n PA$ TO: MONTH/YEARLI7 p`C If no, list the experience you think is equal to a master's degree:  #P #P `3V #P,Arial (-CIf no, list the experience you think is equal to a master's degree: 0`$ P @ Yes     @ No     p Button21&F  # dBlackCell782*dd dl KP P# d8Black Supervisor  `<C / @@X  ~ @@@@@@ @@@@@s*y`{hys?HH Ff>?8 =>HH Ff=>8 <=HH Ff<=8 ;<HH Ff;<8 :;HH Ff:;8 9:HH Ff9:8 89HH Ff898 78HH Ff788 67HH Ff678 56HH Ff568 45HH Ff458 34HH Ff348 23HH Ff238 12HH Ff12H 01HH Ff01H /0HH Ff/0H ./HH Ff./H -.HH Ff-.H ,-HH Ff,-H +,HH Ff+,H *+HH Ff*+H )*HH Ff)*H ()HH Ff()H '(HH Ff'(H &'HH Ff&'H %&HH Ff%&H $%HH Ff$%H #$HH Ff#$H "#HH Ff"#H !"HH Ff!"H !HH Ff !H  HH Ff H HH FfH HH FfH HH Ff< HH Ff< HH Ff< HH Ff< HH Ff< HH Ff< HH Ff< HH Ff< HH Ff< HH Ff< HH Ff< HH Ff2 HH Ff2 HH Ff2 HH Ff2 HH Ff 2 HH Ff 2 HH Ff & HH Ff & HH Ff &  HH Ff & HH Ff& HH Ff& HH Ff& HH Ff& HH Ff& HH Ff& HH Ff& HH Ff N3Submit *XXjj2VXXd'< s$ od6 HTdsInformed Quadra ServerMSA eForms Workplace310210itx 10_210.itxITpxInformed XML Template (*.itx)*application/vnd.shana.informed.xmltemplatelisH propalis porpsila*<EArial`8xJ\ + porpsila porpsila*,Sd'.P .# Page 2 of 4 &##CP MANDATORY TRAINING   r  `#.@/ NSTATEMENT OF QUALIFICATIONS FOR STAFF DSHS 10-210 (REV. 05/2001) (AC 05/2003)  K K   K,Arial (*&STATEMENT OF QUALIFICATIONS FOR STAFF (*(DSHS 10-210 (REV. 05/2001) (AC 05/2003) `#! Title`@(/-n lpp DATE *` @)/-n mp $NAME OF PROGRAM PROVIDING TRAINING -OT O-T  K -OT,Arial (>qNAME OF PROGRAM (GnPROVIDING TRAINING` (@*/-n np  TITLE OF TRAINING *J`(@+n qp8  INSTRUCTOR *5` @,n op p LOCATION/ADDRESS *P` #@-0.n pp # NUMBER OF HOURS -TE -ET -OT -TE,Arial (>NUMBER (G OF HOURS # Title p@) /-n !` DATE *p @* /-n ! &NAME OF THE PROGRAM PROVIDING TRAINING fN Nf -TE fN,Arial (whNAME OF THE PROGRAM (nPROVIDING TRAINING  (@+ /-n  ! TITLE OF TRAINING *J( @, n 8!  INSTRUCTOR *5 @- n ! LOCATION/ADDRESS *P  #@. 0.n  !# NUMBER OF HOURS fE fE fN fE,Arial (wNUMBER ( OF HOURS@ bComplete the following regarding training you received and provide any certificates of completion.     10.   0# iDo you have at least 30 hours of training from an established domestic violence victims advocacy program?   P 11.    # Do you have at least 30 hours of training from a certified domestic violence perpetrator treatment program or an out-of-state domestic violence perpetrator treatment program which meet the standards cited in WAC 388-60?  8'B 8B'  8'B,Arial (BkDo you have at least 30 hours of training from a certified domestic violence perpetrator treatment program ( Bfor an out-of-state domestic violence perpetrator treatment program which meet the standards cited in (B WAC 388-60?p  bComplete the following regarding training you received and provide any certificates of completion.     p 12. Complete the following.   #C` WORK EXPERIENCE   d #$#" # ?> SUPERVISED DIRECT TREATMENT CONTACT WITH PERPETRATORS   6$@@) n c   START DATE *1$ p@@* n d  ` END DATE *( p$@+ n e  !ORGANIZATION PROVIDING EXPERIENCE *$!@@@, n f !0 SUPERVISOR/ACADEMIC CREDENTIALS *!@$#@@- n g !P# HOURS *$-##% $%# 0*DOMESTIC VIOLENCE VICTIM ADVOCACY SERVICES   ,%-@@)& n h&&  START DATE *1%- p@@*& n i&& ` END DATE *(% p-@+& n j& & !ORGANIZATION PROVIDING EXPERIENCE *%-!@@@,& n k&&!0 SUPERVISOR/ACADEMIC CREDENTIALS *%!@-#@@-& n l&!P&# HOURS *P `@p l  q P Yes  *  #p@! l  r!#` No  *   `@ l  s P Yes  *  `# @ ! l  t!# No  *       0 $@@  l @ $ 8If yes, list the school, location, date, and your major:  | /`0P ASTATEMENT OF QUALIFICATIONS FOR STAFF DSHS 10-210 (REV. 05/2001)  7 7 R  7,Arial (&STATEMENT OF QUALIFICATIONS FOR STAFF (DSHS 10-210 (REV. 05/2001) $&(@@ @ "     @BDFHJmnopdiqrst_!"u҆Hɺɱ҆Hɺɺɺɺ`d拺拺ɺɺɺɺɺɺɺɺɺɺɺɺɺɺɺɺɺɺɺɺɺɺɺɺɺɺɺ( propalis propalisN propalisH propalisB porpsila porpsila*<EDataHelmnopq    !"@ABCDEFGHIJKLMPQRS^4_4`4a4b4c-d-e-f-g-h-i-j-k-l-mnopqrstuFALSE`<;\,(;\ @ `<;\;\,l;\ @ H(;\H;\ @tPB ;\;\,@;\ on`<;\,p;\@A`<;\;\,,;\BC`<;\;\,8;\D!E`<;\;\,(;\FHG`<;\;\,;\HuI`<;\;\,;xJ"KtPB ;\,@`;\qp`<;\,;\m n`<;\d;\no`<;\;\,P;\op`<;\;\,;\pPqF;\VBn8}R8} 8}("x6~Bx6161Your end date must be later than your start date.cd@F;\;\@VB~6T6*6(,6~B6161Your end date must be later than your start date.hi@`<;\;\,8;\qrH(;\;\rs`<;\;\,;\sltH(;\;\tcF;\VB:6,66(Lr6~Br6161Your end date must be later than your start date.^_@tPB ;\,;\@ӈ,B@tPB ;\,@d;\DBtPB ;\,@`;\!FDtPB ;\,@`;\"LKtPB ;\,@`;\uJHArialTimes New Roman