Self-Reporting Policy & Form

WEST VIRGINIA CERTIFICATION BOARD FOR ADDICTION AND PREVENTION PROFESSIONALS

POLICY: SELF-REPORTING A RETURN TO USE

Timeframe: A certified entity/applicant must self-report a return to use/recurrence of symptoms/behaviors or behaviors to the board within 10 days of the return to use/recurrence of symptoms/behaviors. This Self-Reporting Form must be completed.

Inactive Status/Plan of Action: If a certified entity or applicant self-reports a return to use or recurrence of symptoms/behaviors, their credential will be placed on inactive status until the Board approves a viable Plan of Action for reentry to practice, ensuring they can safely resume working with clients. To initiate this process, the certified entity or applicant must submit a Plan of Action, a scheduled non-refundable fee, and the self-reporting form to the Board within 10 days of the incident. The Board will review the Plan of Action and determine certification status within 14 days of receiving the self-report form.

Plan of Action: If a certified entity or applicant enters a treatment program, they should ideally self-report before beginning treatment. Self-reporting must include a Plan of Action submitted with the self-reporting form. At a minimum, the Plan of Action must consist of regular reports from the certified entity’s supervisor, as agreed upon by the credentialed individual and the Board. It may include treatment, therapy, additional meetings, or other necessary interventions. The Ethics Committee will review and respond to all self-reports and Plans of Action per the process outlined in Section 6.00 of the WVCBAPP Policies and Procedures.

Self-Reporting After 10 Days: If the certified entity or applicants fails to self-report a return to use/recurrence of symptoms/behaviors within 10 days, the credential will become inactive for a period of no less than thirty (30) days and will be evaluated by the Ethics committee and handled on a case-by-case basis. Final decisions, outlined in Section 6.00 of WVCBAPP Policies and Procedures, could include a reinstatement of the active credential up to an inactive credential until a period of no less than two (2) years of recovery is again reached.

Fees for Self-Report Submittal/Status Change: The credentialed individual must submit a scheduled non-refundable fee when submitting a self-report form. To reinstate their credential, they must submit a request for status change and an additional scheduled nonrefundable fee, subject to the individual, Ethics Committee, and Board approval.

Name*

First NameLast Name

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Certification Status *

Credential(s) Held:*

Date of Self-Report*

Date

Date of Incident *

Date

Company, organization, or employer at the time of the incident:

If unemployed, enter NA

Supervisor's Name

First NameLast Name

Supervisor's Email

example@example.com

Were clients involved in this situation? *

Nature of Incident: (A brief description of the incident, including what happened)*

Describe any actions you have taken to address the situation:*

List and describe the supporting documents you will provide with your submission. Describe any future actions you will take to address the situation (trainings, attended or attending meetings, sponsor work, treatment, additional support through your supervisor or employer, any agreements with the court system or law enforcement): *

Upload the Documents Listed Above:*

If law enforcement is involved, what is the status of the investigation?*

Non-Refundable Self-Report Fee

Self-Report FeeYou may pay the fee using this form. This does have an 8% fee. If you wish to pay by check, please make the check payable to WVCBAPP and mail to the office.

$27.00

Total

$0.00

I attest that the information contained herein is true and correct. I will accept any requirements of the WVCBAPP and will provide regular reports of my actions to WVCBAPP.*

I agreeI disagree

Signature*

Date*

Date

Self-Reporting Policy & Form

Description of Incident