Preservice Training Verification Form
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2Preservice Training Verification Form
Effective Date: 6-15-16
Directions:
1. This form is for
Preservice
and
Title IV-E Stipend Student
applicants, primarily.
Waiver
applicants failing the exam
must submit this form before retesting.
2. If there are multiple training providers, a separate form must be completed by the training providers’ designee,
documenting the specific preservice curriculum component(s) delivered to participants listed in Part 3 of this form.
The only exception is for Title IV-E Stipend Students. The applicant’s training entity Point of Contact will collect and
attach a copy of the official college/university letter that verifies the applicant’s successful completion of the two
required courses that include the content taught in the new DCF Preservice Curriculum, CORE Training modules.
3. The applicant’s training entity designee completes this form.
4. The training entity Point of Contact will collect completed forms and any required supporting documentation,
review for completeness, and scan/email all documents to the FCB certification specialist assigned to their region
NO MORE THAN 5 business days AFTER the exam date. Note: Contact the FCB if you do not know the email address
of the certification specialist assigned to your region.
Part 1: Curriculum Information
1. This form documents:
A single source training provider (not including college/university providers for Title IV-E Stipend Students)
Multiple training providers
2. Identify the specific curriculum delivered to the applicants listed in part 3 of this form.
DCF Preservice Curriculum, Stop-Gap Version
Start Date
End Date
DCF Preservice Curriculum, Employer-Customized Version
Start Date
End Date
New DCF Preservice Curriculum, CORE Training Modules
Start Date
End Date
New DCF Preservice Curriculum, PI Specialty Track Training Modules
Start Date
End Date
New DCF Preservice Curriculum, CM Specialty Track Training Modules
Start Date
End Date
New DCF Preservice Curriculum, LC Specialty Track Training Modules
Start Date
End Date
Other ____________________________________________________
Start Date
End Date
Part 2: Preservice Training Verification Attestation
Name of Training Provider
Name of Primary Trainer
Name of Individual Completing Form
Title
Work Email Address
Work Phone
The applicant(s) named on Part 3 of this form have completed the training indicated in Part 1 of this form.
Yes No
Documentation of successful completion of training is maintained according to agency protocol.
Yes No
I consent to an audit of agency records if requested to verify my attestation.
Yes No
By my signature, I attest that the above material is true to the best of my knowledge.
Signature (FCB accepts both manual and electronic signatures)
Date
Florida Certification Board (FCB)
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