Application for Community Health Worker-Certified (CHW-C)

Application for Community Health Worker-Certified (CHW-C)
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MonthDayYear
Date
Hour MinutesAM/PM Option
First Name*
Middle Initial*
Last Name*
Current Home Street Address*
Current Street Address Line 2
City*
State*
Zip Code*
Please list Maiden Name and Other Names Used*
Cell Phone Number*
List the county you reside in*
Home Phone Number
Work Phone Number
Social Security Number*
Work Extension Phone Number
Email*
example@example.com
Birth Date*

Credential History
Are you currently or have you been credentialed or licensed as a Substance Use Disorder Professional by the MCB or any other state or organization? *

YesNo
If yes, which state/organization and when? *
What is the type of credential/license held with the other state/organization?*

Education/Employment
Please mark the highest level of education completed:*

High School Diploma/HSEAddiction Certificate ProgramAssociate DegreeBachelor DegreeMaster Degree/Higher
Please list Degree Program*
An applicant may document High School Diploma or HSE or College/University degree by:
1. Submitting copy of High School Diploma/HSE
2. Submitting official or unofficial College/University transcripts. Please ensure the transcript shows the applicable degree being conferred.
Please upload education documents here.*

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Training Requirements

Submit documentation of the completed required DHSS approved CHW training program.
Submit documentation of the completed required DHSS approved CHW training program*

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Where Does the Applicant Currently Work?
Are you currently employed?*

YesNo
Name of Employer*
Mailing Address of Employer*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Immediate Supervisor*

First NameLast Name
Title of Immediate Supervisor*

Criminal History and Children’s Division Incidents
Have you ever been CONVICTED of and/or PLEAD GUILTY to a felony (including SIS or SES)?*

YesNo
If you answered "yes".

If you were convicted of and/or plead guilty to a felony (including SIS or SES) listed in Section 630.170RSMo (view www.missouricb.com; Disqualifying Crimes link), you will not be issued this credential without an exception letter from the Department of Mental Health or MCB Exceptions Committee. If you have not completed that process, the instructions for requesting one can be found here.

If your felony conviction requires you to complete the Department of Mental Health Exceptions Committee process, you do not need to complete the Felony Offense Form. Please upload a copy of the Department of Mental Health letter granting the exception.

If your felony conviction is not on the list of Disqualifying Crimes, please go to the www.missouricb.com website, print off the “Felony Offense Form”, fill out the form and submit with your application by uploading it below.
Upload your Felony Offense Form or DMH Exception Letter here:*

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Have you ever knowingly been contacted by a Children’s Division employee regarding a CHILD ABUSE and/or CHILD NEGLECT incident involving you? *

YesNo
IF you answered "yes".

If yes, please go to the www.missouricb.com website, print off the “Child Abuse/Neglect Statement”, fill out the form and submit with your application.
Please upload the Child Abuse/Neglect Statement Here*

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Signature Pages
Applicant’s Agreement to the Code of Ethical Practice and Professional Conduct

I have read the Current Community Health Worker’s Ethics Code as listed on the MCB web site, MCB Ethics Code Link and agree to abide by this code:
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AUTHORIZATION AND RELEASE

I hereby certify all of the information given herein is true and complete to the best of my knowledge and belief. I also authorize any relevant investigations, or the release of personal information to the Missouri Credentialing Board, its agents, or contractors pursuant to this application/renewal procedure. I understand falsification of any portion of this application/renewal will result in my being denied credentialing, or revocation of same upon discovery.

I further agree to hold the Missouri Credentialing Board and its Board Members, officers, agents, staff, peer evaluators and examiners, free from any civil liability for damages or complaints by reason of any action that is within the scope and arise out of the performance of their duties which they, or any of them, may take in connection with this application/renewal, any examination, the grades with respect to any examination, and/or the failure of the MCB to issue me said credential or renewal.

This Authorization and Release shall also apply to personal information requested by the Board at any time following credentialing in connection with any investigation concerning allegations that could lead to disciplinary action against me.
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CHW-C Application Payment*
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Community Health Worker-Certified (CHW-C) Application
$82.50

Total

$0.00
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