Form DDD-1691A FORFF "Article 9 Instructor Application Packet" - Arizona

What Is Form DDD-1691A FORFF?

This is a legal form that was released by the Arizona Department of Economic Security - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2017;
  • The latest edition provided by the Arizona Department of Economic Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DDD-1691A FORFF by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

ADVERTISEMENT
ADVERTISEMENT

Download Form DDD-1691A FORFF "Article 9 Instructor Application Packet" - Arizona

123 times
Rate (4.4 / 5) 7 votes
ARIZONA 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
ARIZONA 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
DDD-1691A FORFF (11-17)
Page 2 of 8
Additional Required Attachments:
Attached?
Article 9 Candidate Assessment ................................................................
Signed Instructor Responsibilities Agreement ...........................................
Letter of Support and Agreement from Supervisor/Agency ........................
Send completed application and required attachments to dddstatewidetraining@azdes.gov.
If you have questions about completing this application, please contact the DDD Training Unit at 602-771-8125.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination
in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability,
genetics and retaliation. To request this document in alternative format or for further information about this policy, contact
the Division of Developmental Disabilities ADA Coordinator at 602-542-0419; TTY/TDD Services: 7-1-1. • Free language
assistance for DES services is available upon request.
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Page 3 of 8
DDD-1691A FORFF (11-17)
Division of Developmental Disabilities
ARTICLE 9 INSTRUCTOR CANDIDATE ASSESSMENT
Article 9 Instructors need a solid foundation in topics including full knowledge of Article 9, positive behavior support,
and positive behavior change strategies, as well as familiarity with Prevention and Support, including emergency
physical intervention techniques.
As part of your application, please answer the following questions completely.
CANDIDATE’S NAME
DATE
1. Identify the six techniques that are specifically prohibited by Article 9 and A.R.S. 36-561.A.
2. When supporting an individual who is displaying challenging behaviors, how does knowing that all behavior is
communication affect your response?
3. Identify four categories of restrictive teaching techniques that require a behavior plan be written and approved
by the planning team, the Program Review Committee, and reviewed by the Human Rights Committee. Provide
an example for each category. (Please provide responses in A, B, C and D below.)
A.
Example:
B.
Example:
DDD-1691A FORFF (11-17)
Page 4 of 8
CANDIDATE’S NAME
DATE
C.
Example:
D.
Example:
4. According to Prevention and Support, what are the three questions that need to be asked to determine is a
situation is a behavioral emergency?
5. Penny has a history of biting people near her when she is frustrated. She often gets frustrated at work when
she does not have enough to do, or if she has to stay on one task for longer than a half an hour. She does not
communicate with spoken words. Friends and staff who have known Penny for a while say she is extremely
expressive with her facial expression and hand gestures. When she is not frustrated, friends and staff say she
does a good job pointing to what she wants and using her face to express her emotions.
What alternative behavior would you want to teach Penny?
Identify 5 positive teaching techniques that could be used to support Penny in learning the alternative behavior.
DDD-1691A FORFF (11-17)
Page 5 of 8
CANDIDATE’S NAME
DATE
6. While teaching a class, one class participant is adamant that seclusion/locked time-out can be an effective
behavior change strategy when working with someone who is upset, particularly if other people are around and
at risk of being injured.
Describe how you would respond to the participant, maintaining the participant’s dignity while reinforcing Article 9
and the principles of Positive Behavior Support.
7. It is Friday night, and a new movie was just released. The movie theater is packed. Cecilia has waited all week
for the movie, and is extremely excited. Cecilia always has popcorn when she goes to the movies.
The line for the snack bar is really long. Cecilia picks a line, and begins to wait. She starts to step back and
forth as she gets worried that she will not get her favorite seat in the theater. She feels like all the other lines are
moving faster, and bites her nails every time another line moves faster.
Finally, the man in front of her reaches the front of the line. He orders a hot dog, and the cashier explains they
will have to cook the hot dog. Cecilia sighs loudly. The cashier says, “Please wait a minute.”
Cecilia shoves the man aside and screams, “I just want popcorn! I need my popcorn now!”
The man quickly moves to the side and says, “It’s okay–just give this woman her popcorn.”
The cashier is so concerned that she quickly fills a bag of popcorn and gives it to Cecilia. The cashier does not
charge Cecilia for the popcorn. Cecilia takes the popcorn and rushes into the theater to find a seat.
Identify the following in the scenario:
Antecedents:
Precursors:
Interfering behavior:
Page of 8