TRAINER RECERTIFICATION APPLICATION

TRAINER RECERTIFICATION APPLICATION
Candidate Information*
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 yes, 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 RecertificationIn Person Recertification
Trainer Recertification Requirements
As a certified trainer, I acknowledge that I understand and have met the following re-certification requirements and am therefore eligible to schedule my Inter-Rater Reliability assessment (IRR).

8 hours of CQL Continuing Education AND

Completion of at least 24 days of POM related professional development consisting of the following activities over the course of the 2-year term:
- A minimum of 2 POM Workshops
  - 1 POM Workshop counts as 4 Days (in-person or virtual)
- A minimum of 6 POM Interviews
  - 1 POM Interview counts as 1 Day (in-person or virtual)
Beyond these minimum requirements, the remaining 10 days may include any combination of the following activities – POM Workshops, POM Interviews, and/or CQL-Approved Customized Training.

If I am certified in both the Adult and Children & Youth POM my 24 days will be split equally between the two measures.
I have fulfilled the above requirements by completing the following number of activities
(Please only enter activities you have already completed)

Continuing Ed*   Hours of CQL Continuing Education
Interviews*   Personal Outcome Measures® Interviews
Workshops*   Personal Outcome Measures® Workshops
Custom Trainings*  Customized Personal Outcome Measures® training as approved by CQL
My agencies Customized Personal Outcome Measures® training(s) have been approved by CQL*

YES
If you need to submit a Customized Personal Outcome Measures® training to CQL for approval you may do so via this link Trainer Certification - Customized Training Submission.
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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TRAINER RECERTIFICATION APPLICATION

Candidate Information

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

Trainer Recertification Requirements

Preferred Dates for Scheduling