SECTION .0700 - FORMS

12 NCAC 09G .0701         REPORT: APPLICATION: AND CERTIFICATION FORMS

(a)  The following are Commission approved forms to be used by the North Carolina Department of Public Safety, Division of Adult Correction and Juvenile Justice in making reports, applications, or requests for certification to the Commission:

(1)           The Medical History Statement. The Medical History Statement is a questionnaire to be completed by an applicant. The form includes information pertinent to the applicant's present and past physical condition, injuries, diseases, or operations.

(2)           The Medical Examination Report. The Medical Examination Report is a form provided to the examining physician to record the results of the applicant's medical examination. The Medical Examination Report is form that includes the following information regarding the applicant:

(A)          contact information;

(B)          date of birth; and

(C)          medical information.

(3)           The Request for School Accreditation Form. The Request for School Accreditation Form provides the means for an agency or institution to become certified to conduct corrections training and to affiliate with the Criminal Justice Education and Training System. It seeks information on the physical, financial, and staff support provided to the school by the agency or institution.

(4)           The Request for Training Course Accreditation Form. The Request for Training Course Accreditation Form is used to obtain accreditation for a school's particular offering of a corrections training course. It requests information regarding the administration of the course, the particular facilities to be used, and the proposed curriculum of the course.

(5)           The Report of Appointment/Application for Certification. The Report of Appointment/Application for Certification is used for reporting the appointment of correctional officers and probation/parole officers, and indicating the applicant's progress toward completing the requirements for certification. The Report of Appointment/Application for Certification form includes the following information:

(A)          type of certification;

(B)          applicant contact information;

(C)          criminal history;

(D)          military history;

(E)           applicant appointment date and position title; and

(F)           medical information.

(6)           Notice of Transfer. The Notice of Transfer form is used to notify the Standards Division of an officer's change in the type of corrections officer certification. The Notice of Transfer form includes the following information:

(A)          applicant information;

(B)          transfer information;

(C)          employment date and title; and

(D)          education completed.

(7)           Report of Separation. The North Carolina Department of Public Safety, Division of Adult Correction and Juvenile Justice, when separating a person from employment as a correctional officer or probation/parole officer shall forward to the Commission a completed Report of Separation or Department of Public Safety Personnel Action Form within 30 days of separation. The Report of Separation form includes the following information:

(A)          type of certification;

(B)          applicant contact information;

(C)          criminal history; and

(D)          applicant appointment date and position title.

(8)           The Request for Instructional Certification Form. The Request for Instructional Certification Form is used by persons seeking certification as general instructors. It seeks information regarding personal and professional background as well as documentation of the specific criteria for certification. The Request for Instructional Certification form includes:

(A)          applicant contact information;

(B)          certification type;

(C)          employment date and title;

(D)          education completed;

(E)           practical experience; and

(F)           recommendation

(9)           The Recommendation for General Instructor Certification Form. The Recommendation for General Instructor Certification Form is completed by a School Director or agency head after an instructor has finished the required probationary period. In the form the official recommends that the instructor receive General Instructor Certification and certifies that the official has observed and evaluated the instructor to be a teaching professional. The Recommendation for General Instructional Certification form includes:

(A)          applicant contact information;

(B)          certification type;

(C)          employment date and title;

(D)          education completed;

(E)           practical experience; and

(F)           recommendation

(10)         The Application for Award of State Corrections Certificate. The Application For Award of State Corrections Certificate requests information regarding the education, training, and experience qualifying the applicant for various levels of certification under the State Corrections Officers' Professional Certificate Program. The Application for Award of State Corrections Certificate form includes:

(A)          applicant contact information;

(B)          certificate type;

(C)          employment date and title;

(D)          education completed;

(E)           practical experience; and

(F)           recommendation

(b)  All forms contained in this Rule may be accessed on the agency's website at http://ncdoj.gov/About-DOJ/Law-Enforcement-Training-and-Standards/Criminal-Justice-Education-and-Training-Standards/Forms-and-Publications.aspx

History Note:        Authority G.S. 17C-6;

Temporary Adoption Eff. January 1, 2001;

Eff. August 1, 2002.

Amended Eff. December 1, 2018;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 25, 2019.