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N. C. Department of Administration North Carolina Council for Women/Domestic Violence Commission Approved Abuser Treatment Program Yearly Renewal North Carolina Administrative Code, Title One – Administration, Chapter 17 – Council on the Status of Women, Section .0700 – Abuser Treatment Programs, sets forth the minimum standards of practice for abuser treatment programs for domestic violence offenders and outlines the procedure for approval of Abuser Treatment Programs by the NC Council for Women/Domestic Violence Commission. 01 NCAC 17 .0702 01 NCAC 17.0703 (a) provides that “In addition to initial approval, each abuser treatment program shall be reviewed annually by the commission.” The following document outlines the procedures and process for the annual review of each approved abuser treatment program by the Council for Women/Domestic Violence Commission as described in the North Carolina Administrative Code. The rules, along with the renewal application, are available at www.nccfwdvc@doa.nc.net or by contacting the CFW/DVC at (919) 733-2455. INSTRUCTIONS: Renewal Process: The Renewal process entails the submission of the following required documents: 1. Completed cover sheet 2. Completed Certification Page form, asserting there were no program changes made since application or last renewal date. This Certification page must be signed by the Agency Director. OR 3. Completed Changes to program form: List any changes made since program application or the last renewal date (including/but not limited to: changes in program Director/direct service staff/group facilitators; program location; curriculum). The Changes form must be signed by the Agency Director. 4. Provide a new/updated Memorandum of Understanding (MOU) with the local Victim Service agency in each county where ATP services are provided. *Renewals will not be complete without a current MOU. 5. New 2010: Stated Abuser Treatment Program Philosophy 6. Completed list of ATP staff members and titles. Direct Service Staff (those responsible for intake and assessment) and Group Facilitators (those responsible for groups). 7. Documentation of continuing education in domestic violence training, for each ATP staff. Direct Service Staff, minimum of 20 hours, and Group Facilitator(s) minimum of 6 hours. This training may be obtained through a combination of internal (i.e., presented within the agency as an in-service, with documentation) and external sources (i.e., regional or state conferences, on-line presentations, with documentation). Renewal Application Postmark Date: February 20 Submit the completed Renewal Application to: The North Carolina Council for Women/Domestic Violence Commission Abuser Treatment Program Coordinator 46 Haywood St. # 309 Asheville, NC 28801 Phone: 828-251-6169 Revised 10/09 N. C. Department of Administration North Carolina Council for Women/Domestic Violence Commission Approved Abuser Treatment Program Renewal Application Date of Renewal: ___________________________ A. Provider Identification (Administrative Location): 1. Name of Agency/Program___ 2. Address 3. Telephone Fax 4. Website (if applicable) _____________________________________________________ 5. Agency/Program Director 6. Email Address ___________________________________________________________ 7. Status: ( ) Public ( ) 501©(3) non-profit ( ) Private-for-profit 8. Gender of Clients Served Males Females 9. Spanish-speaking services provided: Yes  No  Both B. Delivery Site(s): List individual county names and office addresses, including Judicial Districts, of each site where groups are held. (Attach additional sheet if needed) 1. County Location: Address: Telephone: Contact Person: Judicial District: 2. County Location: Address: Telephone: Contact Person: Judicial District: 3. County Location: Address: Telephone: Contact Person: Judicial District: 4. County Location: Address: Telephone: Contact Person: Judicial District: 2 CERTIFICATION I certify that the Abuser Treatment Program, ____________________________________________________________________, (Program and/or name of agency) is in compliance with all rules set out in NC Administrative Code, Title One – Admin., Chapter 17 – Council on the Status of Women, Section .0700 – Abuser Treatment Programs. I further certify that no changes have been made from the original application, or from the last renewal date, and that all information is still accurate. ________________________________ Signature, Agency Director _____________________________ Title _____________________________ Date 3 Submission of Changes to Original Application _____________________________________ submits the following changes or updates (Name of Agency) to the original application for approval by the North Carolina Domestic Violence Commission submitted on: _____________________________________ (original date of application) (List each change and reference the applicable Rule) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ CERTIFICATION I certify that the above information is true and correct and that in all aspects the program is in compliance with the rules set out in North Carolina Administrative Code, Title One – Administration, Chapter 17 – Council on the Status of Women, Section .0700 – Abuser Treatment Programs. _______________________________ Signature, Agency Director ______________________________ Title ______________________________ Date 4 State the Abuser Treatment Program Philosophy _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ List all current Abuser Treatment Program Staff Name Title/responsibility _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 5 CONTINUING EDUCATION CERTIFICATION Reference Rule: 01 NCAC 17 .0712 NOTE: Documentation for all training must be attached Group Facilitator(s): 6 hours each - List each group facilitator separately below: Staff member name Name or type of Training Date of Training # of Hours completed Documentation attached I hereby certify that each group facilitator(s) received a minimum of 6 hours of continuing education or training on domestic violence. _______________________________ Signature, Agency Director _______________________________ Title _______________________________ Date 6 CONTINUING EDUCATION CERTIFICATION Reference Rule: 01 NCAC 17 .0712 Note: Documentation for all training must be attached Direct Service Staff: 20 hours each - List each Direct Service Staff separately below Staff member name Name or type of Training Date of Training # of Hours completed Documentation attached I hereby certify that each Direct Service Staff member received a minimum of 20 hours per year of continuing education or training on domestic violence. _________________________________ Signature, Agency Director _______________________________ Title _______________________________ Date 7