OIS Instructor Candidate Application

Name*

First NameLast Name

Preferred Pronoun*

YesNo

Include the Provider Number. This number can be supplied by the employer you will be teaching for or, if you are the ODDS provider, is listed in eXPRES.*

Address*

Street Address

Street Address Line 2 (optional)

CityState / Province

Postal / Zip Code

Preferred Phone Number*

Format: (000) 000-0000.

Preferred Email*

Alternative Email (if desired)

Company Name (if any):

Will you be bringing a certified interpreter? If so, list the interpreter's name and registry number from the following website: https://hciregistry.dhsoha.state.or.us/*

If interpretation/translation services are required, you must provide interpretation and translation for all OIS events/communication going forward. If you do not have an interpreter hired, indicate that above and notify OIS with the name and registry number no less than 6 weeks prior to the workshop.

How do you intend to use your OIS Instructor Certification? (e.g. train within your agency, train people outside of the IDD system, train PSWs or DSPs outside of your agency, contract with IDD agencies to provide training to their staff, train child welfare)*

Level 0: A Level 0 instructor does not teach any physical skillsLevel 1: A Level 1 instructor is certified to teach all evasions, deflections, escapes (except choke holds and bear hugs), and barriers. A Level 1 instructor can elect to be certified to teach limb shadowing.Level 2: A Level 2 instructor is certified to teach all evasions, deflections, escapes (except choke holds and bear hugs), and barriers. They are also certified to teach Limb Control and Belt/Shirt Variations. A Level 2 instructor can elect to be certified to teach Limb Shadowing, Belt-Arm Pivot, and/or the One-Person One/Two Arm skill(s).Level 3: A Level 3 instructor is certified to teach all evasions, deflections, escapes, releases, and barriers. They are certified to teach Limb Control, Belt/Shirt Variations, Two Person Standing, Two Person Escort, Two Person Couch, and Two Person Wall. A Level 3 instructor can elect to be certified to teach any elective PPI skills, Limb Shadowing, Choke Escapes, and Bear Hug Escapes.Non-Teaching: This certification allows an OIS instructor to use and write OIS language and physical skills techniques including protective physical interventions at their chosen certification level (indicate 1, 2, or 3) into a support plan. This certification level does not teach any OIS workshops but may teach physical skills written within the support plan to someone with a current OIS certificate.

Describe your experience working with individuals who need behavior interventions or support with emotional/behavioral dysregulation. Include how you have at least 1 year experience.*

This can include but is not limited to, direct service or lived experience (e.g., family members). Examples include: Utilizing Positive Behavior Supports (such as person-centered planning, replacement behaviors, positive reinforcement, functions of behavior), experience with behavior/mental health models (such as biopsychosocial, polyvagal theory, learning theories, cognitive behavioral model, positive psychology, applied behavior analysis), experience collaborating with teams of professionals.

Describe any training/teaching experience. This can include other classes you train.*

Add any other applicable experience you would like considered.

Been convicted of a felonyReceived disciplinary action by a professional board in the last three yearsBeen substantiated for abuse in the last three yearsFailed a state background check in the last three yearsReceived disciplinary action by the Oregon Intervention System in the last three years?None of the above

Please upload one or more letter(s) of recommendation.*

Please request a letter of recommendation from someone you know well, preferably a person with experience in Human Services or Education/Training. The letter should include skills you have related to: Training adult learners, Teaching, Utilizing Positive Behavior Supports (such as person-centered planning, replacement behaviors, positive reinforcement, functions of behavior), Other behavior/mental health models (such as biopsychosocial, polyvagal theory, learning theories, cognitive behavioral model, positive psychology, applied behavior analysis), Collaborating with teams of professionals.

Please upload your current OIS certificate. Include both the front and back sides.*

OIS Registration and Refund Policy

Yes

By submitting this application, I attest the information contained within is truthful and accurate.

Signature*