Form DBPR MRS 0704 Application for Continuing Education Course Approval or Renewal - Florida

Form DBPR MRS0704 is a Florida Department of Business & Professional Regulation form also known as the "Application For Continuing Education Course Approval Or Renewal". The latest edition of the form was released in April 1, 2013 and is available for digital filing.

Download a PDF version of the Form DBPR MRS0704 down below or find it on Florida Department of Business & Professional Regulation Forms website.

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State of Florida
Department of Business and Professional Regulation
Mold Related Services
Application for Continuing Education Course Approval or Renewal
Form # DBPR MRS 0704
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
 Complete all sections of this application.
 No fee is required.
 A detailed course outline describing the course’s content and subject
matter, and a written statement that explains in detail how the course
relates to the practice of assessing or remediating mold.
 Sample certificate of course completion
Continuing Education
 Submit a course syllabus.
Course, Initial or
 List the instructors for each course and license number for each
Renewal
instructor.
If the course is interactive submit documents requested in Section III
 Record Keeping: Attendance records must be maintained for a
minimum of 4 years. Attendance records and course completion
information for all course participants must be provided to the
Department in a specified format acceptable to the Department and
within an agreed upon timeframe. These records must be made
available to the Department upon request.
Please mail your completed application, documentation to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, Fl 32299-0780
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. General Requirements for Mold Related Services Continuing Education Course Application
a. All portions of the application must be completed.
b. Continuing education providers must submit a sample course completion certificate with the
application. The sample course completion certificate must include the provider’s name, the
provider’s approval number, the licensee’s name, the licensee’s license number, the
approved course title, the course approval number, the course completion date, and the
number of approved continuing education credit hours awarded in each subject area covered
by the course.
c. Continuing education course applications must include course detail. Course detail includes:
i.
Course Outline: Attach a course outline specifying subjects, major topics, and subtopics
to be covered in the course. Each subject must also include a narrative summary.
ii.
Reference and Source Materials: Include a list of all reference and source materials,
along with their publication date(s), for the course.
iii.
Course Evaluation: Attach a copy of the evaluation forms used to assess the learning
experience, instructional methods, and course materials.
iv.
Instructors: List the instructors for each course, and attach a resume for each instructor
even if previously approved for another course. Instructors must possess sufficient skills
and knowledge in the subject areas being taught.
v.
Record Keeping: Attendance records must be maintained for a minimum of four years.
Attendance records and course completion information for all course participants must be
provided to the Department in a specified format acceptable to the Department and within
an agreed upon timeframe. These records must be made available to the Department
upon request.
DBPR MRS 0704 Application for Continuing Education Course Initial/Renewal
Eff. Date April 2013
Incorporated by Rule 61-31.505
1 of 4
State of Florida
Department of Business and Professional Regulation
Mold Related Services
Application for Continuing Education Course Approval or Renewal
Form # DBPR MRS 0704
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
 Complete all sections of this application.
 No fee is required.
 A detailed course outline describing the course’s content and subject
matter, and a written statement that explains in detail how the course
relates to the practice of assessing or remediating mold.
 Sample certificate of course completion
Continuing Education
 Submit a course syllabus.
Course, Initial or
 List the instructors for each course and license number for each
Renewal
instructor.
If the course is interactive submit documents requested in Section III
 Record Keeping: Attendance records must be maintained for a
minimum of 4 years. Attendance records and course completion
information for all course participants must be provided to the
Department in a specified format acceptable to the Department and
within an agreed upon timeframe. These records must be made
available to the Department upon request.
Please mail your completed application, documentation to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, Fl 32299-0780
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. General Requirements for Mold Related Services Continuing Education Course Application
a. All portions of the application must be completed.
b. Continuing education providers must submit a sample course completion certificate with the
application. The sample course completion certificate must include the provider’s name, the
provider’s approval number, the licensee’s name, the licensee’s license number, the
approved course title, the course approval number, the course completion date, and the
number of approved continuing education credit hours awarded in each subject area covered
by the course.
c. Continuing education course applications must include course detail. Course detail includes:
i.
Course Outline: Attach a course outline specifying subjects, major topics, and subtopics
to be covered in the course. Each subject must also include a narrative summary.
ii.
Reference and Source Materials: Include a list of all reference and source materials,
along with their publication date(s), for the course.
iii.
Course Evaluation: Attach a copy of the evaluation forms used to assess the learning
experience, instructional methods, and course materials.
iv.
Instructors: List the instructors for each course, and attach a resume for each instructor
even if previously approved for another course. Instructors must possess sufficient skills
and knowledge in the subject areas being taught.
v.
Record Keeping: Attendance records must be maintained for a minimum of four years.
Attendance records and course completion information for all course participants must be
provided to the Department in a specified format acceptable to the Department and within
an agreed upon timeframe. These records must be made available to the Department
upon request.
DBPR MRS 0704 Application for Continuing Education Course Initial/Renewal
Eff. Date April 2013
Incorporated by Rule 61-31.505
2 of 4
d. Fee: No fees.
2. Application Instructions (by section)
a. Section I
i.
Check only one of the application types.
ii.
Continuing Education Course Initial
(1)
Select this application type if you are applying for an initial approval of a
continuing education course.
iii.
Continuing Education Course Renewal
(1)
Select this application type if you are applying to have a continuing education
course approval renewed and there have been no changes to the course since
its initial approval.
(2)
If there have been any changes to the course, other than the instructors, you
must select “Continuing Education Course Approval” as the application type and
submit the supporting documentation required of an initial course approval.
b. Sections II
i.
Fill out each section completely.
ii.
Each applicant must provide their name, company or organization name, and their
provider approval number.
iii.
Applicants seeking to renew a course approval must also provide their current course
approval number.
c. Section III
i.
Applicants must provide the course title. The title you choose must adequately define the
content of the course. If you are applying to approve more than one course, please
complete additional applications as necessary.
ii.
Indicate which subject areas will be covered in the continuing education course and the
number of credit hours assigned to each subject area.
iii.
Indicate how the course will be provided to the student by checking the appropriate box.
d. Section IV
i.
Please read and sign the affirmation by written declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
3. Other Information
a. Continuing education course providers shall not advertise a course as approved for
continuing education credit from the Department of Business and Professional Regulation
until the course has been approved by the Department and a course number has been
assigned.
b. Providers should supply all students with a course completion certificate upon completion of
the course.
c. Approved course numbers and course titles should be used in all advertisements.
d. Any substantive changes regarding the provider’s application information must be filed with
the Department within thirty days of the change.
e. Provider approval is valid until May 31 of odd-numbered years and must be renewed.
Providers are responsible for renewing all courses prior to the course expiration date.
f.
Providers must work with licensees to resolve reporting conflicts.
g. Course approval is valid for two years from the date of board approval. Providers must
reapply for course renewal every two years.
Refer to Rule 61-31.501, Florida Administrative Code, for additional information regarding provider
and course requirements.
DBPR MRS 0704 Application for Continuing Education Course Initial/Renewal
Eff. Date April 2013
Incorporated by Rule 61-31.505
3 of 4
State of Florida
Department of Business and Professional Regulation
Mold Related Services
Application for Continuing Education Course Approval or Renewal
Form # DBPR MRS 0704
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
For additional information see the Instructions at the beginning of this application.
Section I – Application Type
CHECK ONE OF THE APPLICATION TYPES
Continuing Education Course Initial [0706/1030]
Continuing Education Course Renewal [0706/2020]
Section II – Applicant Information- Provider
PROVIDER INFORMATION
Last/Surname (Provider)
First
Middle
Suffix
Company/Organization Name
Provider Approval Number
Course Approval # (If renewal)
MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
CONTACT INFORMATION
Contact Name:
Primary Phone Number
Primary E-Mail Address
BUSINESS LOCATION ADDRESS
Street Address
City
State
Zip Code
County (if Florida address)
Country
ADDITIONAL CONTACT INFORMATION (OPTIONAL)
Alternate Phone Number
Fax Number
Alternate E-Mail Address
DBPR MRS 0704 Application for Continuing Education Course Initial/Renewal
Eff. Date April 2013
Incorporated by Rule 61-31.505
4 of 4
Section III – Course Information
COURSE INFORMATION
Course Title:
Course Delivery Method:
Classroom
Interactive Distance Learning
COURSE COMPONENT
Water (Moisture Intrusion)
Mold and Mold Safety
Standards of Practice
Number of Hours:
Number of Hours:
Number of Hours:
Total Number
of Hours:
COURSE INSTRUCTORS
Last/Surname
First
Middle
Suffix
(1)
Last/Surname
First
Middle
Suffix
(2)
Last/Surname
First
Middle
Suffix
(3)
INTERACTIVE DISTANCE COURSES
Interactive Distance courses must submit documents indicating the following:
1. The means by which the course will demonstrate interactivity between the student and course
provider within a maximum of 24 hours, which promotes student involvement, and demonstrates that
the course measures learning and addresses comprehension of content at regular intervals.
2. The means by which the course provider is able to monitor student enrollment, participation and
course completion.
3. The means by which the course provider will be able to satisfactorily demonstrate that stated
course hours are consistent with the actual hours spent by each student to complete the course.
4. The means by which the provider will assure qualified instructor(s) will be available to answer
questions and provide students with necessary support during the course.
5. That the student will be required to complete a statement at the beginning and end of the course
that indicates that he/she personally completed each module/session of instruction.
6. The means by which the course provider will verify student identification.
Section IV – Affirmation By Written Declaration
AFFIRMATION BY WRITTEN DECLARATION
I certify that I am empowered to execute this application as required by Section 559.79, Florida Statutes. I
understand that my signature on this written declaration has the same legal effect as an oath or
affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts
stated in it are true. I understand that falsification of any material information on this application
may result in criminal penalty or administrative action, including a fine, suspension or revocation
of the license.
Signature:
Date:
Print Name:
DBPR MRS 0704 Application for Continuing Education Course Initial/Renewal
Eff. Date April 2013
Incorporated by Rule 61-31.505

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