OIS Instructor Candidate Application

Name

First NameLast Name

Preferred Pronoun

Do you work as/for an ODDS Provider? If you are not sure, please ask your employer.

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 eXPRS.

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)

What instructor level are you pursuing?

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.

Have you:

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

I have read and agree to the Registration and Refund Policy.

After completing the 4-day workshop, I understand that I may need to travel to fulfill the remaining candidacy requirements as outlined on the OIS website in the Train the Trainer information.

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

Signature