Ncsappb Training Approval Request Form
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1MAILING INFO: MARK THE ENVELOPE ATTN: DONNA STRICKLAND OR INDICATE IT IS A
TRAINING APPROVAL REQUEST
Training Approval Request
C
P
______________________________________________________________________________________
ONTACT
ERSON:
O
: _________________________________________________________________________________________
RGANIZATION
A
: _____________________________________________________________________________________________
DDRESS
P
: _____________________ F
: ____________________
E
HONE
AX
MAIL:
________________________________________________________________
T
T
: ______________________________________________________________________________________
ITLE OF
RAINING
D
(
): ______________________________________________________________________________________________
ATE
S
❏ No
❏ Yes
Will This Be Recurring Training?
(If YES, notify Board in advance of additional presentation dates not included on original request.)
L
(
): ___________________________________________________________________________________________
OCATION
S
S
(
): ___________________________________________________________________________________________
PONSOR
S
P
(
): [Résumés must be attached unless presenter is credentialed with the Board or has previously presented Board
RESENTER
S
approved training(s)]
___________________________________________________________________________________
______________________________________________________________________________________________________
Attach B
B
T
D
T
I
R
S
A
(Substance abuse specific training
RIEF
UT
HOROUGH
ESCRIPTION OF
RAINING AS
T
ELATES TO
UBSTANCE
BUSE
is education which directly addresses content focused upon alcohol and other drugs and the substance abusing population and
is provided for substance abuse professionals by one whose expertise is in the field of alcohol and other drugs.)
Requested # of Substance Abuse Specific Hours _____
If included in course curriculum, please designate hours of HIV_____ Ethics_____ ND _____ PSY _____ EBT _____
SAOA _____ SAV _____ CSS _____ (Definitions of abbreviations are available in the Trainings section of the website
( )
Attach B
T
D
T
I
R
G
P
S
B
(General skill
ENERAL
ROFESSIONAL
KILL
UILDING
RIEF BUT
HOROUGH
ESCRIPTION OF
RAINING AS
T
ELATED TO
building training is any training provided to enhance the professional skills of the participants and is provided by a competent
professional in the area of the training.) Requested # of General Skill Building Hours ______
T
#
C
H
R
_________ (Agenda/Breakout of hours and outline must be attached. If breaks are not
OTAL
OF
REDIT
OURS
EQUESTED
scheduled, the Training Committee will subtract 15 minutes for each two (2) hours of training. For college courses give
semester/quarter hours.)
Hours applied for (circle as appropriate)
SS
GSB
CSS
Combination
Attached Review Fee: __________
1 – 10 hours = $25;
31–40 hours = $100;
(Fee must be received prior to review)
11–20 hours = $50;
41–50 hours = $125;
21–30 hours = $75;
51–100 hours = $150;
41–50 hours = $125;
100 hours & up = Special Review & Fee
FOR BOARD USE ONLY:
T
E
A
______________________________
RAINING
VENT
PPROVAL CODE:
A
:
______________________________
HOURS
PPROVED
C
S
A
P
P
B
N
ORTH
AROLINA
UBSTANCE
BUSE
ROFESSIONAL
RACTICE
OARD
PO Box 10126 • Raleigh, NC 27605 • 919/832-0975
NOTE: APPROVAL OF HOURS DOES NOT IMPLY NCSAPPB ENDORSEMENT OF EVENT
For additional information on training approvals, please refer to Section 4 of the Administrative Rules on the Board’s website
( ). Make special note of the section indicating “Sponsors or presenters shall submit requests for approval prior to the event and shall
allow the Board 45 days for review and approval. Requests by sponsors or presenters postmarked after the event has taken place shall not be reviewed nor
approved by the Board, but shall be returned.”
NCSAPPB Training Approval Request – 2014.04
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