PHPCB ERC Certification Application

Application for Emergency Response Coordinator Certification
Welcome!

Thank you for considering the certification process offered by the Public Health Practitioner Certification Board. We look forward to receiving your application.

Before you apply for certification, you must have the following minimum requirements:
1. A bachelor's degree from an accredited college or university.
2. At least three years of administrative and three years supervisory experience in the public or private health sector (these can occur during the same time period).
Things to know about the application:
1. You will be asked to provide evidence of fulfilling specific competencies through either experiential or through documented educational achievement, or a combination of both.
2. All competencies must be fulfilled for the Board to accept the application for review.
3. You will need to provide a resume or CV, as well as transcripts.

Applicant Information
Name*

First NameLast Name
Address for Correspondence*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email*
example@example.com
Employer
Title/Position

Education
Please list most recent institution first.

Supervisory Experience
List job titles and dates in reverse chronological order.
For each position above, please list the supervisory experience you had in that role.

Administrative Experience
List job titles and dates in reverse chronological order. (Administrative Experience relates to planning, directing, and coordinating activities that help an organization run efficiently.)
For each position above, please list the administrative experience you had in that role.

Resume/CV
Upload your resume or CV.*

Browse Files

Cancelof

Transcripts
Upload your transcripts.*

Browse Files

Cancelof

Evidence
I will be submitting (please select one)*

Experiential EvidenceEducational EvidenceCombination of Both

Signature - Validity of Information
The above statements and the accompanying documentation are true and correct to the best of my knowledge. By signing this form, I attest to their validity. *

Powered by Jotform SignClear

Experiential Evidence

The documentation verifying your competency-based experience should be completed by attester(s) (credible individuals who are familiar with your work experience, who can verify competency and provide SPECIFIC EXAMPLES of activities in which you demonstrated a specific competency). The application requires that you do the following:

1. You should contact your attesters to ask them a) if they will attest to your competency-based experience and b) whether they would prefer to complete the forms with or without specific examples provided by you.

2. For each attester, complete the Attester Information report below.

3. If the attester wants specific examples provided by you, then pre-fill the forms before you send them to the attester. (The attester may accept, edit and/or add examples of your experience).

4. Applicant is responsible for downloading evidence forms, prefilling, and distributing to attesters. Attesters should email completed forms to Lanie Kepler, lkepler@ipha.com.

Attester Information
Attester Contact Information
Academic Evidence

1. If using ONLY academic evidence for a Competency Area, list at least 45 contact hours of graduate level courses and upper level undergraduate courses. Where a sufficient number of formal academic courses/contact hours are not available to substantiate the competencies in any given area, CE courses/training activities and the related number of contact hours can be included.

To calculate contact hours for courses: 1 semester hour = 15 contact hours; 1 quarter hour = 10 contact hours. For CE and/or training activities: contact hours = actual contact hours in learning/training, excluding meals and breaks.

2. If using academic evidence as a supplement to or in combination with experiential evidence, then the applicant should use their judgment regarding what courses and/or CE information would really support a specific competency area. The information should provide evidence that the applicant has acquired a level of knowledge from the courses/CE activities that would contribute to their ability to discuss and/or demonstrate the competency for which the information is submitted. Also, where academic evidence is being used ONLY as a supplement to experiential evidence and to support a specific competency, then the minimum 45 contact hours per Competency Area does not apply.

3. When using evidence of academic coursework, course descriptions (such as those from a syllabus) must be submitted (upload supplemental documents at the end of this application) in order to provide some detail on the content of the course. This information will be valuable in showing the relevance of course content to the competency.

4. When using evidence of CE and/or training, provide documents (such as certificates of completion) that note the names of the CE and/or training activities, actual contact hours and dates of attendance. If contact hours are not provided on the certificate, then provide a copy of the page from the program or agenda that would confirm the contact hours for the activity. Please clearly mark which Competency Area the documentation is being used for. Upload supplemental documents at the end of this application.

Please Note: Many courses taken for an MPH degree will satisfy competency requirements however, the degree itself may not satisfy them all.

Attestation Forms
Reminder: Applicant is responsible for downloading evidence forms, prefilling, and distributing to attesters. Attesters should email completed forms to Lanie Kepler, lkepler@ipha.com.

Download Each Form Here:

Public Health Practice Form

Community Health Assessment Form

Public Health Policy, Advocacy, and Law Form

Program Development and Evaluation Form

Public Health Emergency Preparedness and Response Form

Environmental Health Form

Applied Epidemiology Form

Infectious Disease Preparedness and Response Form

Competency Area: Public Health Practice

The applicant has an in-depth understanding of and/or extensive experience with the basic principles, tools and processes of public health practice, in terms of working with and through the various institutions, organizations, and individuals that contribute to carrying out public health's core functions and essential services in the community.
1. Describe public health as a system, including its unique and important features, to general audiences.
Provide an example of how the course you listed above meets this competency.
2. Apply measures of population health and illness, including risk factors, to community health improvement initiatives.
Provide an example of how the course you listed above meets this competency.
3. Identify and distinguish public health and prevention strategies from curative strategies for prevalent health problems.
Provide an example of how the course you listed above meets this competency.
4. Describe the role of law and government in promoting and protecting the health of the public and identify specific functions and roles of governmental public health agencies in assuring population health.
Provide an example of how the course you listed above meets this competency.
5. Identify and explain how various organizations, positions and roles contribute to carrying out public health's core functions and essential services.
Provide an example of how the course you listed above meets this competency.
6. Identify, measure, and assess the components of the public health infrastructure.
Provide an example of how the course you listed above meets this competency.
7. Apply principles derived from the basic public health sciences to planning, implementing, and evaluating public health interventions.
Provide an example of how the course you listed above meets this competency.
Competency Area: Community Health Assessment

The applicant has an in-depth understanding of and/or extensive experience with the basic principles, tools, and methods of community health improvement processes.
1. Describe assessment in public health, including its unique and important features, to general audiences.
Provide an example of how the course you listed above meets this competency.
2. Obtain, apply, and interpret measures of population health status that are commonly used in community health improvement processes.
Provide an example of how the course you listed above meets this competency.
3. Obtain, apply, and interpret measures of community capacity that are commonly used in community health improvement processes.
Provide an example of how the course you listed above meets this competency.
4. Obtain, apply, and interpret qualitative measures of community health that are commonly used in community health improvement processes.
Provide an example of how the course you listed above meets this competency.
5. Develop and apply a logic model demonstrating interrelationships among risk and protective factors for population health that are commonly used in community health improvement processes.
Provide an example of how the course you listed above meets this competency.
6. Utilize research, evaluation, and strategic planning tools commonly used in community health improvement processes and apply the results of these activities in deciding on an appropriate course of action.
Provide an example of how the course you listed above meets this competency.
7. Identify and apply principles for community engagement and participation in community health improvement processes.
Provide an example of how the course you listed above meets this competency.
Competency Area: Public Health Policy, Advocacy, & Law

The applicant has an in-depth understanding of and/or extensive experience with the basic principles, tools, and processes for policy development, advocacy and law in public health.
1. Describe advocacy and policy development in public health, including its unique and important features, to general audiences.
Provide an example of how the course you listed above meets this competency.
2. Identify and apply theories and approaches that drive public health policy-making for important public health issues.
Provide an example of how the course you listed above meets this competency.
3. Apply advocacy and agenda-setting principles to formulate public health policy.
Provide an example of how the course you listed above meets this competency.
4. Apply principles of public health law and its legislative processes to formulate and implement public health policy.
Provide an example of how the course you listed above meets this competency.
5. Apply principles of public health law and its regulatory processes to implement public health policy.
Provide an example of how the course you listed above meets this competency.
6. Apply principles of public health law and its operational processes to implement public health policy.
Provide an example of how the course you listed above meets this competency.
7. Understand the process of implementing and managing policy to achieve desired outcomes.
Provide an example of how the course you listed above meets this competency.
Competency Area: Program Development & Evaluation

The applicant has an in-depth understanding of and/or extensive experience with the principles, tools, and processes for developing and evaluating public health programs.
1. Describe program development and evaluation in public health, including its unique and important features, to general audiences.
Provide an example of how the course you listed above meets this competency.
2. Plan a public health program.
Provide an example of how the course you listed above meets this competency.
3. Develop a public health program.
Provide an example of how the course you listed above meets this competency.
4. Implement a public health program.
Provide an example of how the course you listed above meets this competency.
5. Design and evaluate a public health program.
Provide an example of how the course you listed above meets this competency.
6. Evaluate outcome and cost implications of public health programs.
Provide an example of how the course you listed above meets this competency.
7. Evaluate the impact of public health programs on different populations and cultures and use evaluation results to make evidence-based program decisions.
Provide an example of how the course you listed above meets this competency.
Competency Area: Public Health Emergency Preparedness and Response

The applicant has an in-depth understanding of and/or experience with the principles, tools and process for preparedness and response to public health emergencies, including bioterrorism events and threats.
1. Describe public health roles, including their own level of participation, in emergency an disaster preparedness and response activities.
Provide an example of how the course you listed above meets this competency.
2. Participate in bioterrorism-related public health preparedness and response activities.
Provide an example of how the course you listed above meets this competency.
3. Plans for disasters and public health emergencies, includingplanning for bioterrorism events.
Provide an example of how the course you listed above meets this competency.
4. Apply principles and tools of emergency and disaster response management to public health emergencies, including bioterrorism events and threats.
Provide an example of how the course you listed above meets this competency.
5. Apply principles and tools of emergency and disaster surveillance and assessment to public health emergencies, includingbioterrorism events and threats.
Provide an example of how the course you listed above meets this competency.
6. Apply principles and tools of emergency and disaster recovery and evaluation to public health emergencies, including bioterrorismevents and threats.
Provide an example of how the course you listed above meets this competency.
7. Apply risk communication principles and tools to public health emergencies, including bioterrorism events and threats.
Provide an example of how the course you listed above meets this competency.
Competency Area: Environmental Health

The applicant has an in-depth understanding of and/or experience with the principles, tools and process of community environmental health practice.
1. Recognize environmental health issues in the community and identifies government and community organizations that are resources on environmental issues.
Provide an example of how the course you listed above meets this competency.
2. Recognize human health effects of environmental exposures int heir community and identifies government and community organizations that are resources in environmental issues.
Provide an example of how the course you listed above meets this competency.
3. Apply principles and tools of environmental risk assessment in completing a comprehensive quantitative risk assessment of potentially hazardous environmental and workplace settings.
Provide an example of how the course you listed above meets this competency.
4. Apply principles and tools of environmental risk and assessment in completing a comprehensive qualitative risk assessment, including onsite evaluations of potentially hazardous environmental and workplace settings.
Provide an example of how the course you listed above meets this competency.
5. Apply principles and tools of effective risk communication in addressing community concerns about environmental hazards.
Provide an example of how the course you listed above meets this competency.
6. Apply principles and tools of quantitative exposure assessment in addressing community concerns about environmental hazards.
Provide an example of how the course you listed above meets this competency.
7. Apply principles and tools of environmental prevention and control program development in addressing community concerns and environmental hazards.
Provide an example of how the course you listed above meets this competency.
Competency Area: Applied Epidemiology

The applicant has an in-depth understanding of and/or experience with the principles, tools and applications of epidemiology and basic biostatistics to public health practice.
1. Describe key features and applications of descriptive and analytic epidemiology.
Provide an example of how the course you listed above meets this competency.
2. Calculate and interpret ratios, proportions, incidence rates, mortality rates, prevalence and years of potential life lost.
Provide an example of how the course you listed above meets this competency.
3. Calculate and interpret means, medians, modes, ranges, variance, standard deviations, and confidence intervals.
Provide an example of how the course you listed above meets this competency.
4. Prepare and apply tables, graphs, and charts such as arithmetic scales, lines, scatter diagrams, pie charts, and box plots.
Provide an example of how the course you listed above meets this competency.
5. Describe the processes, uses, and evaluation of public health surveillance.
Provide an example of how the course you listed above meets this competency.
6. Participate in the various steps involved in an outbreak investigation.
Provide an example of how the course you listed above meets this competency.
Competency Area: Infectious Disease Preparedness and Response

The applicant has an in-depth understanding of and/or experience with the principles, tools and process of infectious disease preparedness, prevention, and control.
1. Describe infectious disease preparedness, prevention, and control in public health.
Provide an example of how the course you listed above meets this competency.
2. Apply principles and tools of infectious disease control to vaccine preventable infectious diseases.
Provide an example of how the course you listed above meets this competency.
3. Identify smallpox infections from signs, clinical history, and other evidence, and collect timely data for prevention and control of an outbreak.
Provide an example of how the course you listed above meets this competency.
4. Identify anthrax infections from signs, clinical history and other evidence, and collect timely data for prevention and control of an outbreak.
Provide an example of how the course you listed above meets this competency.
5. Identify Category A, B, and C biological agents (other than smallpox and anthrax) and their unique characteristics and relevance to bioterrorism events and threats from signs, clinical history, and other evidence, and collect timely data for prevention and control of an outbreak.
Provide an example of how the course you listed above meets this competency.
6. Identify emerging infections from signs, clinical history, and other evidence, and collect timely data for prevention and control of an outbreak.
Provide an example of how the course you listed above meets this competency.

Supplemental Information

Please upload any supplemental documents, including course descriptions, additional transcripts, certificates of completion, etc.
Browse Files

Cancelof

Application Fee*
prevnext( X )
PHPCB ERC : IL Resident Application Fee$175.00
PHPCB ERC : IL Resident Application Fee

PHPCB ERC : Non IL Resident Application Fee$350.00
PHPCB ERC : Non IL Resident Application Fee

Total $0.00
Should be Empty:

Application for Emergency Response Coordinator Certification

Competency Area: Public Health Practice

Competency Area: Community Health Assessment

Competency Area: Public Health Policy, Advocacy, & Law

Competency Area: Program Development & Evaluation

Competency Area: Public Health Emergency Preparedness and Response

Competency Area: Environmental Health

Competency Area: Applied Epidemiology

Competency Area: Infectious Disease Preparedness and Response