Practice Sample
Submitted in Partial Fulfillment of the Requirements for
Board Certification by the
American Board of Police & Public Safety Psychology
FULL NAME
Title/Affiliation
Address
City/State/Zip
Phone: (Area Code) Phone Number
Fax: (Area Code) Fax Number
Email: email address
Month Day, Year (of submission)
Digital Signature
Version 6
Revised December 1, 2013
ABPPSP Practice Sample Submission Checklist
The ABPPSP Practice Sample Submission Checklist is a tool to assist Candidates in the technical preparation of the
Practice Sample. The ABPPSP requires Candidates to carefully adhere to both the substantive and technical
requirements outlined in the Examination Manual. Failure to adhere to the technical requirements in their entirety may
result in the Practice Sample being rated as unacceptable.
I attest to each of the following statements in regards to the preparation and submission of my Practice Sample
(please check each box, sign and date):
Examination Manual (EM) Version 9 was relied upon to prepare my Practice Sample.
The written components of the Practice Sample are submitted as digital media in common format (e.g.,
Acrobat PDF or other common digital reading format) and collated into a single document.
The cover or title page contains the required elements as outlined in the Examination Manual.
The Practice Sample is submitted using Calibri 12-point font. No cursive or decorative fonts have been used
unless part of the original document included in a Work Sample. All pages are clear and legible. If copies of
handwritten notes are included, they must be transcribed if they are not reasonably expected to be legible to
the reviewers.
The Practice Sample is free of misspellings, errors of punctuation and grammar, as well as pagination and
formatting errors.
The Table of Contents (TOC) page numbers correctly correspond with the pagination for the entirety of the
submission. The PDF page numbers are consistent with the document page numbers. The TOC clearly identifies
the location of each required element of the Practice Sample.
The Professional Self-Study Statement is no less than 15 pages and does not exceed 25 pages.
The Work Sample materials do not exceed 200 (8 1/2 x 11 inch) pages, inclusive of all attachments and exhibits
(excluding the CV and PSSS), unless the NCE agreed to and provided a written waiver of this requirement.
Work Sample materials presented under the Traditional Option have been collected within two years prior to
advancement to candidacy and submitted within one year after advancement to candidacy, unless a written
extension was requested of, and provided by, the NCE.
Sections within the Practice Sample are clearly labeled with headings. As an example, “Section A: Professional
Activities” rather than “Section A” or “Professional Activities” alone.
“Section F: Ethical Base” section includes no fewer than two complex ethical dilemmas in which there are
substantial clinical, ethical, risk management, legal or other competing issues or values. The dilemmas
sufficiently demonstrate ethical reasoning capacity by detailing the competing elements, factors, and
considerations in addressing each concern/complication, decision(s), and the supportive reasoning.
“Section H: Complex Relationships” section includes two or three examples of substantially complex
interpersonal interactions (e.g., conflicts or disagreements in work relationships, challenging relationship
dilemmas with clients/patients) in one or more of the domains of assessment, intervention, operations, and/or
consultation in police and public safety psychology. Sufficient detail is included to demonstrate the complexity
of these interpersonal interactions, as well as detailed thought processes in negotiating or resolving these
interactions. An explanation for the choice of examples is provided to demonstrate reasoning and acumen in
complex relationships. Each example describes how management of these complex relationships has altered
or impacted psychological practice.
“Section J: Self-Assessment” section includes professional goals for the future.
Each element in the Work Sample (whether Traditional or Senior Option) is preceded by a detailed narrative of
the background and context in which it was generated, and the purpose of its inclusion in the Work Sample
(i.e., what foundational and functional competencies the Work Sample is intended to demonstrate).
Work Samples are redacted and all identifying information is removed and replaced either by deleting or
blacking out names or by assigning fictitious identities. (To maintain professionalism, please do not use
comical or facetious names.) A Practice Sample may be disqualified if confidentiality, privacy, and privilege are
not adequately protected, and/or if identities unnecessary to demonstrating competence are not redacted. (N.B.
While Candidates must redact all identifying information, Candidates may submit Work Samples that identify
and include a video image of a recipient of confidential clinical services if the client has been properly informed
and authorizes the use of the video for purposes of the Practice Sample review. The signed, written
authorization must contain a proper notification that the video and any other identifying information will be
digitally uploaded and transmitted via the Internet to the NCE, the Practice Sample Coordinator, the Practice
Sample Review Panel, and, if an acceptable Practice Sample is achieved, an Oral Examination Panel of three
examiners. Alternatively, a confidential intervention or consultation Work Sample video in which the facial
image of the confidential client is pixilated is acceptable. Video intervention recordings are optional, not
required.)
I have completed, signed and dated the Ethics Attestation Form (Appendix D, p. 69).
A “Consent to Use Educational and Occupational Data from Practice Sample Submitted to the American Board
of Police & Public Safety Psychology” form (Appendix C, p. 67) is included as the last page of the Practice
Sample.
I attest that my Practice Sample follows the instructions of the ABPPSP Examination Manual Version 9. I have
completed, signed and dated the Practice Sample Submission Checklist and included it as the second and third
pages of the Practice Sample. I understand that if this submission fails to adhere to the requirements detailed
above in their entirety, my Practice Sample may be found unacceptable.
____________________________________________
Signature of Candidate
____________________________________________
Name of Candidate
___________________
Date
TITLE PAGE
Practice Sample Submission Checklist.............................................................................2-3
Table of Contents……………………………..............................................................................XX
Curriculum Vitae ......................................................................................................... XX
Professional Self-Study Statement (15-pages min., 25-pages max., single-spaced) ....... XX
A. PROFESSIONAL ACTIVITIES ................................................................................... XX
B. SERVICE TO THE PROFESSION ................................................................................ XX
C. CONTINUING EDUCATION .................................................................................... XX
D. SCIENTIFIC BASE ............................................................................................... XX
E. LEGAL BASE ..................................................................................................... XX
F. ETHICAL BASE................................................................................................... XX
G PRACTICE STANDARDS ........................................................................................ XX
H. COMPLEX RELATIONSHIPS ................................................................................... XX
H. INDIVIDUAL & CULTURAL DIVERSITY ...................................................................... XX
I. SELF-ASSESSMENT..................................................................................................... XX
Informed Consent and/or HIPAA-Related Documents .................................................. XX
DOCUMENT #1 .................................................................................................... XX
DOCUMENT #2 .................................................................................................... XX
DOCUMENT #3 .................................................................................................... XX
DOCUMENT #4 .................................................................................................... XX
Traditional Work Samples (200 pages maximum) ........................................................ XX
WORK SAMPLE #1 ................................................................................................ XX
WS #1 Addendum A .................................................................................. XX
WS #1 Addendum B .................................................................................. XX
WS #1 Addendum C .................................................................................. XX
WORK SAMPLE #2 ................................................................................................ XX
WS #2 Addendum A .................................................................................. XX
WS #2 Addendum B .................................................................................. XX
WS #2 Addendum C .................................................................................. XX
OR
Senior Option Portfolio Work Sample (200 pages maximum) ....................................... XX
WS Addendum A .............................................................................................. XX
WS Addendum B .............................................................................................. XX
WS Addendum C .............................................................................................. XX
WS Addendum Z .............................................................................................. XX
Ethics Attestation........................................................................................................ XX
Research Consent...........................................................................................................XX
Curriculum
Vitae
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Curriculum Vitae of
FULL NAME
EDUCATION
Ph.D. Degree, University, City, State; Conferred Month, Year
M.A. Degree, University, City, State; Conferred Month, Year
B.A.
Degree, University, City, State; Conferred Month, Year
LICENSURE & BOARD CERTIFICATION
Licensed Psychologist, State of XX, Year First Licensed (#License Number)
Board Certified in XX, American Board of Professional Psychology,
American Board of XX Psychology, Year of Board Certification (#Diploma Number)
PROFESSIONAL PRACTICE
Brief Description
TEACHING EXPERIENCE
University/College, Position: Year(s)
PROFESSIONAL ASSOCIATIONS, OFFICES, ACTIVITIES, AND RECOGNITIONS
Association, Membership Status (since Year)
Member, XX Committee (Year-Year)
SELECTED PUBLICATIONS
List citation(s) in APA Publication Manual format
CONTINUING POSTGRADUATE EDUCATION &TRAINING:
List all continuing education
OTHER:
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Professional Self-Study
Statement
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Professional Self-Study Statement by
FULL NAME
Date of Submission
A. Professional Activities:
Please describe your professional work, organized as follows:
1.
A narrative description of how your career in police and public safety psychology
began and developed. Many candidates consider this autobiographical exercise to be one of
the more personally meaningful elements of the examination process, inasmuch as it
provides an opportunity to review and consolidate the influences that helped shape their
careers.
2.
A narrative description of your past, current and anticipated professional practice,
both within the specialty of police and public safety psychology and in other areas of
professional psychology. With reference to only those activities within the four (4) domains
of practice and fifty-seven (57) PPSP activities described in Appendix A in which you practice
or have practiced, please describe the full range of your knowledge and experience in the
field of police and public safety psychology. If there are areas of PPSP in which you have not
heretofore engaged but have interest and intent for future practice, please identify these
and describe your plans in this regard. Your response(s) to this section must also
demonstrate the manner in which your activities and anticipated activities intersect with all
other functional domains and demonstrate conversance in each domain of PPSP that is not
an area of your practice.
3.
Identify the one or two domains you consider to be the primary focus of your
practice in police and public safety psychology. (Note: Traditional Option candidates must
choose Work Samples that reflect the areas defined as their primary practice. Senior Option
candidates must include in their Work Sample portfolio sufficient detail to enable the PS
Review Panel to evaluate their functional competence in these one or two domains.)
4.
A brief statement describing your reasons for seeking board certification.
B. Service to the Profession:
Please describe the services and activities you have provided to the profession of
psychology in general, as well as services and activities specific to the police and public
safety psychology specialty (e.g., volunteer participation on association committees,
presentations at conferences, service in an elected or appointed position at the local, state,
or national level, psychology-related community service).
C. Continuing Education:
Description of the continuing education you have received in police and public safety
psychology during the preceding three years. Repeating the same material you
submitted in the initial stage of your board certification application as a guide, list each
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specific course title, presenter, date and location of presentation, and hours of
continuing education in this section. Elaborate on the nature, content, importance, and
personal professional impact of your recent continuing education experiences.
D. Scientific Base:
It is expected that candidates for board certification in PPSP will respond to this area by
referencing, in the most comprehensive terms possible, the totality of evidence that
informs her/his practice. This evidence may be published or unpublished. Sometimes
this evidence is rigorous, quantitative, scientific and published in a peer-reviewed
journal. At other times it may not have been objectively evaluated (e.g., presentations
at professional meetings and users groups or descriptions and findings that appear in a
technical manual of a test). Other times the evidence is descriptive and/or anecdotal.
Other parochial evidence may be designed for presentation to nonprofessional
audiences or appear in nonscientific media (e.g. trade magazines, popular media, etc.)
where an independent professional review of the design, findings, and conclusions of
this evidence has not been performed prior to dissemination (or has not been
performed in depth or with rigor). It is incumbent upon the practitioner to demonstrate
how they carefully review and critically evaluate this information prior to incorporating
it into their PSSS.
When preparing a response to the Scientific Base, the candidate should review his/her
practice protocol, identify the instruments, procedures and protocols used, and
familiarize her/himself with the evidence base relevant to the primary domain(s) of
practice. In all cases, candidates should summarize both supportive and limiting factors.
Please describe the way(s) in which research evidence informs your practice of police
and public safety psychology by addressing each of the following:
1.
Describe the research evidence you consider in your primary domain(s) of
practice, as well as the ways in which you review, evaluate and integrate this evidence
in your practice, with specific reference to:
a.
Your choice of instruments, batteries, treatment procedures and/or practice and
consultation protocols, and the empirical evidence, with citations, that you relied upon
to support your choices
b.
Your procedures for measuring, evaluating, and improving the effectiveness of
your activities as a police and public safety psychologist
Link the Science Base narrative to the Work Samples you submit in order to illuminate
the research that informs your work. If your practice includes use of existing published
assessment instruments, your response must include 1) a brief summary of the
validation evidence supporting these instruments, 2) a description of what you consider
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to be the attributes and the limitations of these instruments, 3) how you interpret
findings of these instruments, and 4) how you evaluate results of your work. If your
practice includes intervention, operations or consultation, your response should include
the research evidence you considered and continue to rely upon in support of these
activities.
If your practice includes use of instruments and/or processes which are of original
design, please describe these in detail, including 1) your rationale for design and use of
these instruments, 2) how they address limitations of existing instruments, 3) contribute
to the field, etc. In addition, please include relevant technical information in support of
these instruments in your Work Sample.
Include proper citations and a reference section using current APA publication
guidelines (this requirement applies to the entire PSSS). A Candidate’s statements
should be supported by evidence (i.e., cited sources) unless they are original and not
peer-reviewed, in which case that should be explicitly stated.
2.
Describe your past and/or anticipated research activities.
If your practice activities have included research (alone or in collaboration with others),
please describe these studies and provide a summary of your procedures and findings
(and/or reprint, if available) within your Work Sample.
If your practice activities have not heretofore included research, please develop a
statement addressing what research you have considered and/or might consider
conducting in the future. Your discussion should include a description of the key
scientific issues and design considerations, as well as a brief summary of (obtained or
anticipated) procedures and results.
Provide full citations for all published references included in your discussion. If a
reference is not publically available, include a reprint as an appendix at the end of the
PSSS. Note: Pages from all sections (e.g., Work Sample, appendices, HIPAA-related
forms) other than the CV and PSSS cannot exceed 200 pages without written permission
from the NCE.
E. Legal Base:
Please discuss the primary legal framework that guides your activities in your primary
area(s) of practice. Your discussion must include a brief discussion of each of the
primary laws and regulations in your jurisdiction, and any relevant case law that you
consider foundational in your primary areas of practice in police and public safety
psychology. It must include a discussion of the law and court decisions that guide your
understanding of the procedural and civil rights of the public safety personnel served by
you in your practice, any limitations on the actions of psychologists in your area(s) of
practice (e.g., preemployment psychological evaluations at the pre-offer and/or postoffer stages, fitness-for-duty evaluations, critical incident interventions, operations).
Your discussion is not expected to be a comprehensive discussion of all relevant statutes
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and case law, but it must include those that most inform, guide, and structure your
practice. In addition, briefly reference and discuss no fewer than two foundational or
core regulations, statutes or court decisions in domains in which you do not practice. In
order to demonstrate conversance in these areas, explain how or why the cited legal
references are foundational to competent practice.
You must attach copies of all informed consent, HIPAA, statements of understanding and
other related disclosure documents used in your practice. If your practice does not
include one or more forms that would reasonably be expected by your examiners (e.g.,
HIPAA Privacy Statement or informed consent document), please provide an explanation.
F. Ethical Base:
Please describe no fewer than two meaningful and challenging ethical dilemmas that
you have personally encountered in your practice of police and public safety psychology.
Your description must include the manner in which these issues relate to specific
aspects of the APA Ethical Principles of Psychologists and Code of Conduct (EPPCC) (i.e.,
cite the specific EPPCC Standards relevant to the two dilemmas). Provide a detailed
explanation of the factors that made these ethical dilemmas challenging, and indicate
how you chose to influence, resolve and manage the outcome of these dilemmas.
Include how involvement or lessons learned in these ethical dilemmas has altered or
impacted the way you practice. You must submit dilemmas in which there are
substantial clinical, ethical, risk management, legal or other competing issues or values.
Simply providing your resolution to a straightforward ethical violation is insufficient. The
dilemmas must sufficiently demonstrate your ethical reasoning capacity by detailing the
competing elements, factors, and considerations in addressing each
concern/complication, your ultimate decision, and the reasoning supporting your
decision (including the reason(s) you did not choose the alternative(s)).
In conjunction with the submission of the Professional Self-Study Statement, you must
complete a written attestation in regard to any ethical or legal action that has been
taken and/or any investigation that has been initiated subsequent to your application
for and progression to candidacy (see Appendix D).
.
Note: The Board will suspend action on any Applicant or Candidate who is being
investigated by the Ethics Committee of the American Psychological Association, the
American Psychological Society, a state board of psychologist examiners, or the ABPP
Ethics Committee. It is the Applicant’s responsibility to notify the Board of any prior
adverse ethical or licensure determinations. The Board may initiate procedures to revoke
the certification of an individual if it obtains information indicating that the person may
have committed misconduct subject to the Ethics Rules and Procedures of the ABPP.
G. Practice Standards:
Please discuss the practice standards (e.g., guidelines, authoritative treatises, consensus
among published authors) that inform your practice in the domains and activities in
which you practice. If your practice departs from practice guidelines or standards in any
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way, you must discuss and explain the ways in which this occurs, as well as the rationale
(legal, ethical, practical or otherwise) for the departure.
H. Complex Relationships:
Please provide two or three examples of how you have handled complex interpersonal
interactions (e.g., conflicts or disagreements in work relationships, challenging
relationship dilemmas with clients/patients) in one or more of the domains of
assessment, intervention, operations, and consultation in police and public safety
psychology. Include sufficient detail to demonstrate the complexity of these
interpersonal interactions, as well as your thought process, in detail, in negotiating or
resolving these interactions. Explain why you chose the particular examples to
demonstrate your reasoning and acumen in complex relationships. Include how
management of these complex relationships has altered or impacted the way you
practice. You must submit examples which are substantially complex. Simply providing
your resolution to a straightforward relationship problem is insufficient.
I. Individual & Cultural Diversity:
Please discuss how your work in police and public safety psychology is informed by an
awareness of, and sensitivity to, diversity (i.e., individuals, groups and communities who
represent various cultural and personal backgrounds and characteristics). Identify and
explain resources that you draw upon to inform your practice. If assessment is one of
your practice areas, you must discuss how you monitor and address adverse impact.
J. Self-Assessment:
Discuss how you have evolved, grown and improved as a psychologist in the specialty of
Police & Public Safety Psychology, and what improvements you seek to make in your
professional functioning. Please include professional goals for the future.
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Informed Consent and/or
HIPAA-Related Documents
Page 9
Traditional Work Sample
or
Senior Option Portfolio
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Ethics Attestation
American Board of Police & Public Safety Psychology
Please read the following statements and sign below:
I attest that:
1. My psychology license in any jurisdiction has never been revoked, suspended, restricted, subject to
material conditions, or voluntarily relinquished;
2. A governmental body, the American Psychological Association, the Canadian Psychological Association or
any affiliated state, provincial, or territorial association has not determined that I have committed
professional misconduct, or violated material rules of such body; and
3. I am not currently under investigation by any governmental body, the American Psychological Association,
the Canadian Psychological Association or any affiliated state, provincial, or territorial association as a
result of an allegation of professional misconduct or violation of one or more material rules of such body.
Furthermore, I agree that I shall advise the ABPP Board of Trustees within thirty days of the occurrence of the
following events: my psychology license in any jurisdiction is revoked, suspended, restricted, subject to material
conditions, or voluntarily relinquished; or a governmental body, the American Psychological Association, the
Canadian Psychological Association or any affiliated state, provincial, or territorial association, determines that I
have committed professional misconduct, or violated material rules of such body. This reporting obligation exists
regardless of the pending outcome of any appeal or other proceedings related to the triggering event.
If the matter you report is relatively minor, ABPP will simply note your cooperation in the reporting process.
However, if that matter is major, it will be reviewed by the Ethics Committee of the American Board of
Professional Psychology. If you are currently under investigation (see #3 above), the ABPP and ABPPSP will
suspend further examination until the investigation is completed and a determination has been rendered.
I hereby attest that the preceding statement and any attached information is true, complete, and accurate to the
best of my knowledge and belief.
Signature of Candidate
Date
Name of Candidate
Page 11
Consent to Use Educational and Occupational Data from American Board of Police and Public
Safety Psychology (ABPPSP) Practice Sample
As a part of its mission, the American Academy of Police and Public Safety Psychology (AAPPSP)
is developing and maintaining a national database of the educational and occupational history
of Police and Public Safety Psychologists. Through understanding how PPS psychologists have
been and are being trained and the activities in which they engage, we hope to be able to
identify existing educational and occupational opportunities, and future training needs for the
profession. The first step is to summarize the current training and occupational activities of PPS
psychologists. Those data are readily available in the Practice Samples submitted by candidates
for Board Certification. As a candidate for Board Certification, we are asking you to allow the
Director of the AAPPSP to review your submitted Practice Sample to extract anonymous data
on your training and experiences, to be added to a database summarizing such activities.
I, _______________________________________________, authorize/do not authorize (circle
one) the Director of the AAPPSP to be provided with a copy of my Practice Sample, and to use
the data on education, training, and occupational experiences from my submitted Practice
Sample as part of a summary of the educational and occupational history of Police and Public
Safety Psychologists. I understand that any identifying information that would allow me to be
identified as an individual will not be included in summaries of the data; only group summary
information will be presented. Only the Director of the AAPPSP will have access to identifying
information. Only data on educational, training, and occupational experiences will be collected
from the Practice Samples. No proprietary information of any kind will be collected.
The Director of the AAPPSP agrees to properly delete and/or destroy all confidential digital
material upon completion of the data collection.
I may revoke this consent at any time, in writing, by notifying the Director of the AAPPSP. At
that time, my data will be removed from the database, and will not be used in any future
summaries.
____________________________________________
Signature
_____________________
Date
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