INTERVIEWER RECERTIFICATION APPLICATION

INTERVIEWER RECERTIFICATION APPLICATION
Candidate Information
Full Name (exactly as it should appear on certificate)*

First NameLast Name
Job Title*
Organization*
Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Supervisor's Name*

First NameLast Name
Supervisor's Email*
example@example.com
Has your name or contact information changed since your last certification? If so, provide us with your previous contact information.
My certification expires*

MonthDayYear
I want to renew certification in the following measure(s)*

Adult Personal Outcome Measures® (POM)Children and Youth Personal Outcome Measures® (POM)BOTH Adult & Children and Youth Personal Outcome Measures® (POM
I am interested in*

Virtual CertificationIn Person Certification
Interviewer Recertification Requirements
As a certified interviewer, I acknowledge that during the last two-years, I have met the following requirements and I am eligible to schedule my reliability assessment to be considered for another two-year certification period.

If a Certified Interviewer in one of the Personal Outcome Measures®:
- I have completed a minimum of eight (8) hours of CQL Continuing Education, AND
- I have completed a minimum of twenty (20) Personal Outcome Measures® Interviews
If a Certified Interviewer in both measures:
- I have completed a minimum of eight (8) hours of CQL Continuing Education, AND
- I have completed a minimum of thirty (30) Personal Outcome Measures® Interviews, with at least fifteen (15) in each measure.
I have fulfilled the above requirements by completing the following number of activities (Please only enter activities you have already completed)
CE Hours* Hours of CQL Continuing Education
POM Interviews* Personal Outcome Measures® Interviews
If you have not completed the requirements for recertification, please share your plans to fulfill them by the expiration date
Preferred Dates for Scheduling

The QES assigned to your activity will work with you to find a date that works for all the involved parties. *PLEASE NOTE* CQL is not able to guarantee these dates for your activity, but will do our best to accommodate whenever possible.
1st Choice

MonthDayYear
2nd Choice

MonthDayYear
3rd Choice

MonthDayYear
Signature*
Signature*

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INTERVIEWER RECERTIFICATION APPLICATION

Candidate Information

Has your name or contact information changed since your last certification? If so, provide us with your previous contact information.

Interviewer Recertification Requirements

Preferred Dates for Scheduling