Form Ddd-1691a - Article 9 Instructor Application Packet
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8ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1691A FORFF (11-17)
Page 1 of 8
Division of Developmental Disabilities
ARTICLE 9 INSTRUCTOR APPLICATION PACKET
APPLICANT INFORMATION
DATE OF APPLICATION
LOCATION OF REQUESTED CLINIC
DATE OF CLINIC
APPLICANT’S NAME
WORK PHONE NUMBER
EMAIL ADDRESS
BUSINESS ADDRESS (No., Street, Ste. No.)
CITY
ST ATE
ZIP CODE
AGENCY NAME
CURRENT JOB TITLE AND DESCRIPTION
Description of professional experience, including a minimum of 1 year personal and/or professional experience providing
direct support to persons with developmental disabilities (this does not include administrative responsibilities):
I wish to become an Article 9 Instructor because (minimum one paragraph):
DOCUMENTATION
DATE COMPLETED
REQUIRED TRAININGS
REQUIRED
(i.e., certificate)
Teaching and skill building strategies
Principles of positive behavior support, functional behavior analysis
and/or other positive behavioral change systems consistent with Article 9
Article 9 (new instructors: certification must be within the past 6 months;
recertifying instructors: last class roster must be within past 6 months)
Prevention and Support Certification class (either Prevention and Support
certificate or “Preventing Behavioral Incidents” certificate, documenting
observation of the emergency physical intervention techniques)
See page 2 for EOE/ADA/LEP/GINA disclosures
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