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Embed code for: Verification of Receipt of SOM & Required Trainings Doc
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Applied Behavior Analysis Solutions
P.O. Box 832
Pinellas Park, FL 33780
Phone: (727) 492-5369 Fax: (727) 545-8429
Verification of Receipt of Standard Operations Manual and List of Required Trainings/Certifications
I, _____________________________________, agree that I have received copies of the following documents:
I have received a copy of the Standard Operations Manual consisting of agency-specific policies and procedures either via hard copy, CD or sent in an electronic format. I understand that this document may be modified in the future and I will be notified of changed and provided with any revised versions. ________ initial
I have received a copy of a list of training certifications required by the Agency for Persons with Disabilities (APD) for providing services to the population of individuals with developmental disabilities. ________ initial
I understand that the trainings listed in the “Required Trainings/Certifications” document are required by APD in order to work with the specified population and that deadlines apply for obtaining these certifications (as specified on the required trainings document).
I understand that failure to obtain or maintain any or all of the required certifications may result in one or several of the following until the certification is obtained: (1) removal of cases or (2) temporary suspension of payment for services rendered. In some cases, failure to obtain or maintain any or all of the required certifications may result in termination of my contractual agreement with ABA Solutions, Inc.
If I have additional questions documentation, I can ask the administrator, agency officers, other office personnel, or a Senior Behavior Analyst with the agency.
Date Position of Contractor at time of signature
Name of Contractor Signature of Contractor
Name/Position of Witness Signature of Witness
** Witness should be agency administrator, officers, or other agency administration personnel