Be sure you have the most up to date curriculum and student hand out notebook!
You need 10 CEU’s to renew the applications.
Have you created a Instructor’s ad on the NCCDP Instructor’s only portion of the site?
Yes
If no, will you be completing the ad in the next 30 days
Yes
If no, please explain why?
Has your name changed in the last two years?
Yes
If yes, what was name on your last application?
First Name:
Middle Initial:
Last Name:
Personal Address
Has your address changed in the last two years?
Yes
Home address:
City:
State:
Zip Code:
International please complete:
Home Phone:
Cell:
Email Address:
Employment Info
Name of Company
Work Address:
Company Web Address:
Business Phone:
Present Position (title and description):
Work Email:
Seminar Presentation Info
In the past 2 years, have you presented the NCCDP® approved Alzheimer’s & Dementia Care Curriculum as an approved NCCDP® instructor? NCCDP counts the seminar double contact hours for each calendar year. For example, 1 class is 14 contact hours.
Yes
If yes, please provide the Dates:
If no, please explain why.
Did you email or fax all sign in sheets?
Yes
If No, when will you send those to the NCCDP?
Did you post all seminars, in house trainings, facility training and conferences on the web site for the NCCDP Seminar Calendar?
Yes
If no, please explain?
If you have not taught the seminar at minimum one time per year, please explain why?
Do you have plans to present the NCCDP Alzheimer’s and Dementia seminar in the next twelve months?
Yes
Have you purchased new training materials which is the NCCDP Power Point and a Master hand out notebook?
Yes
If no, do you plan on teaching the NCCDP Alzheimer's and dementia seminar?
If yes, what year did you last purchase the updated curriculum as it is updated every two years?
What year did you purchase new training materials?
If no, please explain.
Did you download the free staff in-services for NCCDP Alzheimer’s and Dementia Staff Education Week?
Yes
Have you developed a web site?
Yes
If yes what is the Web Address:
Licensure/Certification Information
Initials (not your title) after your name: (Ex. ADC, RN, LCSW, CNA)
Are you currently in good standing with your other license or certification? (Ex RN,LPN)
Yes
If no, Please explain:
List the license or certification numbers:
What state holds your license or certification?
What government agency or certifying body do you have your license or certification with (Example NCTRC)?
The NCCDP verifies a percentage of the renewals with the governing registries.
I acknowledge that my name will be placed on the NCCDP Instructor & CDP registry located on the web site.
YOUR ADDRESS WILL NOT
Your Initial:
You are required to complete 10 hours of Continuing Education on any health care related topic within 24 months of your renewal date. You are not required to mail in the CE certificates with the CDP or instructor renewal.
Statement that you have completed the required 10 hours of Continuing Education :
Please place your initial in the following field to indicate everything you have stated in the renewal application is true:
Your initial:
Do not send verifying documentation with this form. You are to maintain your certificates of CE or CEU’s for three years following renewal, certificates documenting successful completion of Continuing Education (CE) showing the date and title of the CE program, the number of Continuing Education Units (CEU’s) or contact hours awarded and a certifying signature or other certification of the approved provider. A random audit of CE completion is periodically conducted to verify the preceding statement. The CDP / Instructor selected for the audit must provide these original documents to the NCCDP by the deadline specified by the NCCDP audit notice.
Code of Ethics
The CDP provides services to the health care profession with respect and dignity to the Dementia Client.
The CDP recognizes and respects the Dementia Client individuality.
The CDP participates in ongoing education and stays current with regards to Dementia issues and the National Council of Certified Dementia Practitioners Body of Knowledge.
The CDP maintains competence in his chosen profession.
The CDP will report to the National Council of Certified Dementia Practitioners any acts by a Certified Dementia Practitioner that is illegal or unethical.
The CDP assumes absolute responsibility for your own individual actions.
The CDP will stay current with certifications with the National Council of Certified Dementia Practitioners.
The CDP insures the privacy of the dementia client and applies all HIPPA Regulations.
The CDP works to implement innovative ideas to the health care setting that may help a Dementia Client.
The CDP works to insure that quality of life is provided for the Dementia Clients residing in your health care setting.
The CDP networks with other health care professionals, attends Dementia / Alzheimer’s Seminars, Conventions, Support Groups and Ethics Committees.
The CDP respects the Dementia Clients customs, religious beliefs, and philosophy.
The CDP is truthful and avoids providing false or misleading Information.
The CDP will not use the National Council of Certified Dementia Practitioners on any brochure or advertising without the express permission of this organization and in no way benefit directly or Indirectly at the expense of the National Council of Certified Dementia Practitioners.
The CDP understands that its certification with the National Council of Certified Dementia Practitioners does not in any way confer upon the CDP any type of licensure as a health care provider.
Type your name to indicate that you have read the Code of Ethics:
All renewals require review and signing a new Instructor agreement and new licensee agreement once you have submitted your renewal.
Your Initial:
Upon completing the renewal process, the NCCDP corporate office will send you a new License Agreement and Instructor Agreement. These must be signed and returned to the NCCDP corporate office before your new Instructor certification can be issued to you.
