DSPATHS
CERTIFICATE OF
INITIAL PROFICIENCY
(CIP)
Effective- 1/1/12
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Certificate of Initial Proficiency (CIP) Portfolio
Table of Contents
Section # Contents
1
Portfolio Title Page
Professional Commitment Statement (Essay)
Letter/Communication of Support (at least one letter of support from a
person the participant supports, or their family member or if a person is
unable to verbally communicate and does not have family members, then a
member of their support network)
Training/Education Records- (DSPATHS CIP Transcript)
2
3
4
5
6
7
Effective- 1/1/2014
Signed Pledge to the NADSP Code of Ethics
Work Sample Summary – Communication
Portfolio Permission Form (s)
Work Sample Summary - Community Living Skills and
Supports
Portfolio Permission Form (s)
Work Sample Summary – Elective
Portfolio Permission Form (s)
Work Sample Summary – Elective
Portfolio Permission Form(s)
CIP Candidate Statement of Portfolio Authenticity
Candidacy Application for the Certificate of Initial Proficiency
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 2 of 29
Portfolio Title Page - Certificate of Initial Proficiency (CIP)
Candidate’s Name:
Candidate’s Home Telephone Number:
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Candidate’s Work Telephone Number:
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Candidate’s Cell Phone Number:
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Candidate’s Email Address:
Candidate’s Address:
Candidate’s Employer:
Employer Telephone Number:
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Please Check Employer Type:
Organization:
Individual Provider:
Candidate’s Skill Mentor Name:
Candidate’s Skill Mentor Work Telephone Number:
Candidate’s Skill Mentor Cell Phone Number:
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Candidate’s Skill Mentor Email Address:
Candidate’s Skill Mentor Address:
,
Date of Submission:
/
/
*Please note that all areas on this form must be filled in, if an area does not apply,
please mark as N/A.
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 3 of 29
Professional Development Essay
Please type your essay below and make sure you answer the questions that are included
in the Professional Development Essay Worksheet.
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© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 4 of 29
Letter/Communication of Support
Name of person served or their representative:
Please note: Recommendation may be supplied in an audio or video format
accompanied by this form that is signed by the individual or the individual’s
representative.
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 5 of 29
Training/Education Records
(DSPATHS CIP Class Transcript)
Date
Module
Class Title
Instructor
Time
Total
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 6 of 29
Pledge to the NADSP Code of Ethics
I
have read and understand the NADSP Code of Ethics. I hereby pledge to uphold
and honor the NADSP Code of Ethics in my daily practice and follow the guiding
principles contained within the Code. Those principles include:
Person Centered Supports: I will pledge my first allegiance to the person(s) I support.
Promoting Physical and Emotional Well-Being: I am responsible for supporting the
emotional, physical and personal well-being of the individuals receiving support.
Integrity and Responsibility: I will support the mission and vitality of my profession.
Confidentiality: I will safeguard and respect the privacy of the people I support.
Justice, Fairness and Equity: I will affirm the human rights, civil rights and
responsibilities of the people I support.
Respect: I will respect the human dignity and uniqueness of the people I support.
Relationships: I will assist the people I support to develop and maintain relationships
Self Determination: I will assist the people I support to direct the course of their own lives.
Advocacy: I will advocate with the people I support for justice, inclusion, and full
community participation.
I agree to accept this Code of Ethics as my standard of practice in this field.
_
_______________________
Candidate’s Name
Effective- 1/1/2014
_
Date
_____
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 7 of 29
Work Sample Summary - Certificate of Initial Proficiency (CIP)
Competency Area: Communication
Candidate:
Skill Mentor:
Please complete the following questions by typing your answers in the box provided
underneath each question.
1. What is the problem, concern or goal you are addressing?
2. How did it come to your attention?
3. What specifically did you do to resolve the problem, address the concern, or further
the goal you have presented?
4. What was the outcome of your actions?
5. What process did you go through in getting the collaboration of the person served
and, if applicable, their representative(s) to participate in this work sample?
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 8 of 29
The skill standards of this competency area are listed below. These are the
specific areas the portfolio review team will use to evaluate your work sample.
Area 2: Communication: The Direct Support Professional should be knowledgeable
about the range of effective communication strategies and skills necessary to establish
a collaborative relationship with the participant.
Skill Statements
2A. The competent DSP uses effective, sensitive communication skills to build
rapport and channels of communication by recognizing and adapting to the range
of participant communication styles.
2B.The competent DSP has knowledge of and uses modes of communication that
are appropriate to the communication needs of participants.
Explain how the actions you took demonstrate your skills in standards A and B in
the area of Communication.
(2A) How did you adapt to the individual communication style(s) by using your
effective, sensitive communication skills to build a relationship with the
individual(s) you have selected for this work sample?
(2B) Describe the method or approach of communication that you used with the
individual(s) in this work sample. Why (or how) was this method appropriate?
Effective- 1/1/2014
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Please provide an actual sample of the work you did to demonstrate your
competency in this area. Work samples can be in the form of videos (must be able
to be viewed by graders via private You Tube link, Google Drive, Dropbox, etc..),
documentation, pictures, diagrams, testimonials, etc…
Please insert your work sample here for Communication.
Reflective Statement:
Please write a statement reflecting on your experience with this work sample and
describe what you learned.
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 10 of 29
Work Sample Summary - Certificate of Initial Proficiency (CIP)
Competency Area: Community Living Skills & Supports
Candidate:
Mentor:
Please complete the following questions by typing your answers in text fields.
1. 1. What is the problem, concern or goal you are addressing?
2. How did it come to your attention?
3. What specifically did you do to resolve the problem, address the concern, or further
the goal you have presented?
4. What was the outcome of your actions?
5. What process did you go through in getting the collaboration of the person served
and, if applicable, their representative(s) to participate in this work sample?
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 11 of 29
The skill standards of this competency area are listed below. These are the
specific areas the portfolio review team will use to evaluate your work sample.
Area 6: Community Living Skills & Supports
The Direct Support Professional has the ability to match specific supports and interventions
to the unique needs of individual participants and recognizes the importance of friends,
family and community relationships.
Skill Statements
6A. The competent DSP assists the participant to meet his or her physical (e.g., health,
grooming, toileting, eating) and personal management needs (e.g., human development,
human sexuality), by teaching skills, providing supports, and building on individual
strengths and capabilities.
6B. The competent DSP assists the participant with household management (e.g., meal
prep, laundry, cleaning, decorating) and with transportation needs to maximize his or her
skills, abilities and independence.
6C. The competent DSP assists with identifying, securing and using needed equipment
(e.g., adaptive equipment) and therapies (e.g., physical, occupational and
communication).
6D. The competent DSP supports the participant in the development of friendships and
other relationships.
6E. The competent community based support worker assists the participant to recruit and
train service providers as needed.
Explain how the actions you took demonstrate your skills in standards A and B and
one additional standard of your choice (C, D, or E) in the area of Community
Living Skills & Supports.
(6A) How do you assist the individual(s) you work with to meet their physical (e.g.
health, grooming, toileting, eating, etc…) and personal management needs (e.g.,
human development, human sexuality, etc…) by teaching skills, providing
supports, and building on their individual strengths and capabilities?
(This answer does not need to be directly related to this work sample.)
(6B)
How do you assist the individual(s) you work with in the area of household
management activities to maximize their skills, abilities, and independence.
(This answer does not need to be directly related to this work sample.)
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Choose one additional standard of your choice (C, D, or E).
(6C) In your work sample, how did you identify, secure, and use adaptive equipment
and/or therapeutic techniques (i.e. physical, occupational, and communicative).
(6D) In your work sample, how did you support the individual(s) in the
development of friendships and other relationships.
(6E) In your work sample, how did you assist the individual to recruit and train service
providers as needed.
Effective- 1/1/2014
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Please provide an actual sample of the work you did to demonstrate your
competency in this area. Work samples can be in the form of videos (must be able
to be viewed by graders via private You Tube link, Google Drive, Dropbox, etc..),
documentation, pictures, diagrams, testimonials, etc…
Please insert your work sample here for Community Living Skills and Supports.
Reflective Statement:
Please write a statement reflecting on your experience with this work sample and
describe what you learned.
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 14 of 29
Work Sample Summary - Certificate of Initial Proficiency (CIP)
Elective Competency Area: Documentation
(Candidates MUST choose two elective work sample areas.)
Candidate:
Skill Mentor:
Please complete the following questions by typing your answers in text fields.
1. What is the problem, concern or goal you are addressing?
2. How did it come to your attention?
3. What specifically did you do to resolve the problem, address the concern, or further
the goal you have presented?
4. What was the outcome of your actions?
5. What process did you go through in getting the collaboration of the person served
and, if applicable, their representative(s) to participate in this work sample?
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 15 of 29
The skill standards of this competency area are listed below. These are the
specific areas the portfolio review team will use to evaluate your work sample.
Area 12: Documentation
The Direct Support Professional is aware of the requirements for documentation in his or
her organization and is able to manage these requirements efficiently.
Skill Statements
12A. The competent DSP maintains accurate records, collecting, compiling and
evaluating data, and submitting records to appropriate sources in a timely fashion.
12B. The competent DSP maintains standards of confidentiality and ethical
practice.
12C. The competent DSP learns and remains current with appropriate
documentation systems, setting priorities and developing a system to manage
documentation.
Explain how the actions you took demonstrate your skills in standards A, B, and C
in the area of Documentation.
(12A) What were the results of the documentation you collected? (Evaluate and
summarize the data your documentation form collected.)
How, and with whom, did you share the results of your data?
What process did you go through in getting the collaboration of the individual(s)
and/or staff to participate in this work sample?
(12C) In general, how do you learn and remain current with appropriate documentation
systems?
Effective- 1/1/2014
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(12B) In general, how do you maintain standards of confidentiality and ethical
practices?
Please provide an actual sample of the work you did to demonstrate your
competency in this area. Work samples can be in the form of videos (must be able
to be viewed by graders via private You Tube link, Google Drive, Dropbox, etc..),
documentation, pictures, diagrams, testimonials, etc…
Please insert your work sample here for Community Living Skills and Supports.
Reflective Statement:
Please write a statement reflecting on your experience with this work sample and
describe what you learned.
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 17 of 29
Work Sample Summary - Certificate of Initial Proficiency (CIP)
Elective Competency Area: Assessment
(Candidates MUST choose two elective work sample areas.)
Candidate:
Skill Mentor:
Please complete the following questions by typing your answers in text fields.
1. What is the problem, concern or goal you are addressing?
2. How did it come to your attention?
3. What specifically did you do to resolve the problem, address the concern, or further
the goal you have presented?
4. What was the outcome of your actions?
5. What process did you go through in getting the collaboration of the person served
and, if applicable, their representative(s) to participate in this work sample?
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 18 of 29
The skill standards of this competency area are listed below. These are the
specific areas the portfolio review team will use to evaluate your work sample.
Area 3: Assessment
The Direct Support Professional should be knowledgeable about formal and informal
assessment practices in order to respond to the needs, desires and interests of the participants.
Skill Statements
3A. The competent DSP initiates or assists in the initiation of an assessment process by
gathering information (e.g., participant's self‐assessment and history, prior records, test
results, additional evaluation) and informing the participant about what to expect
throughout the assessment process.
3B. The competent DSP conducts or arranges for assessments to determine the needs,
preferences, and capabilities of the participants using appropriate assessment tools and
strategies, reviewing the process for inconsistencies, and making corrections as
necessary.
3C. The competent DSP discusses findings and recommendations with the participant in a
clear and understandable manner, following up on results and reevaluating the findings as
necessary.
Explain how the actions you took demonstrate your skills in standards A, B, and C
in the areas of Assessment.
(3A) How did you Initiate or assists in the assessment process by gathering information
(i.e., individuals’ self-assessment and history, prior records, test results, evaluation
results, additional evaluations) and informing the individual about what to expect
throughout the assessment process?
(3B) How did you conduct or arrange for assessments to determine the needs,
preferences, and capabilities of the individual using appropriate
assessment tools and strategies, reviewing the process for inconsistencies,
and making corrections as necessary?
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 19 of 29
(3C) How did you discuss the findings and recommendations with the individual, the
Xteam, and or their family in a clear and understandable manner?
How did you follow up on the results and reevaluate the findings if necessary?
Please provide an actual sample of the work you did to demonstrate your
competency in this area. Work samples can be in the form of videos (must be able
to be viewed by graders via private You Tube link, Google Drive, Dropbox, etc..),
documentation, pictures, diagrams, testimonials, etc…
Please insert your work sample here for Assessments.
Reflective Statement:
Please write a statement reflecting on your experience with this work sample and
describe what you learned.
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 20 of 29
Work Sample Summary - Certificate of Initial Proficiency (CIP)
Elective Competency Area: Person Directed Supports
(Candidates MUST choose two elective work sample areas.)
Candidate:
Skill Mentor:
Please complete the following questions by typing your answers in text fields.
1. What is the problem, concern or goal you are addressing?
2. How did it come to your attention?
3. What specifically did you do to resolve the problem, address the concern, or further
the goal you have presented?
4. What was the outcome of your actions?
5. What process did you go through in getting the collaboration of the person served
and, if applicable, their representative(s) to participate in this work sample?
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 21 of 29
The skill standards of this competency area are listed below. These are the
specific areas the portfolio review team will use to evaluate your work sample.
Area 14: Providing Person Centered Supports
Skill Statements
14A. The competent DSP provides support to people using a person centered
approach.
14B. The competent DSP modifies support programs and interventions to ensure they
are person centered.
14C. The competent DSP challenges co‐workers and supervisors to use person
centered practices.
14D. The competent DSP is knowledgeable about person centered planning
techniques.
14E. The competent DSP assists individuals in developing person centered plans.
Select three standards of your choice and explain how the actions you took
demonstrate your skills in the area of Person Centered (Directed) Supports.
Person Centered (Directed) Supports
(14A) How did you provide support to people using a person centered (directed)
approach?
(14B) How did you modify support program(s) and interventions to ensure they
are person centered?
(14C) How did you encourage co-workers and supervisors to use person centered
(directed) practices?
(14D) How did you use person centered (directed) planning techniques?
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Page 22 of 29
(14E) How did you assist individuals in developing person centered (directed) plans.
Please provide an actual sample of the work you did to demonstrate your
competency in this area. Work samples can be in the form of videos (must be able
to be viewed by graders via private You Tube link, Google Drive, Dropbox, etc..),
documentation, pictures, diagrams, testimonials, etc…
Please insert your work sample here for Person Directed Supports.
Reflective Statement:
Please write a statement reflecting on your experience with this work sample and
describe what you learned.
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
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Work Sample Summary - Certificate of Initial Proficiency (CIP)
Elective Competency Area: Supporting Health and Wellness
(Candidates MUST choose two elective work sample areas.)
Candidate:
Skill Mentor:
Please complete the following questions by typing your answers in text fields.
1. What is the problem, concern or goal you are addressing? How did it come to your
attention?
2. What specifically did you do to resolve the problem, address the concern, or further
the goal you have presented?
3. What was the outcome of your actions?
4. What process did you go through in getting the collaboration of the person served to
participate in this work sample?
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 24 of 29
The skill standards of this competency area are listed below. These are the
specific areas the portfolio review team will use to evaluate your work sample.
Area 15: Supporting Health and Wellness Promotes the health and wellness of all
consumers.
Skill Statements
15A. Administers medications accurately and in accordance with agency policy
and procedures.
15B. Observes and implements appropriate actions to promote healthy living and
to prevent illness and accidents.
15C. Uses appropriate first aid/safety procedures when responding to
emergencies.
15D. Assists individuals in scheduling, keeping, and following through on all
health appointments.
15E. Assists individuals in completing personal care (e.g., hygiene and grooming)
activities.
15F. Assists with identifying, securing and using needed adaptive equipment (i.e.
adaptive equipment) and therapies (e.g., physical, occupational, speech,
respiratory, psychological).
15G. Assists individuals in implementing health and medical treatments.
15H. Assists individuals to take an active role in their health care decisions.
Select five standards of your choice and explain how the actions you took
demonstrate your skills in the area of Supporting Health and Wellness.
(15A) In general, how do you administer medications accurately and in accordance with
applicable policies and procedures?
(15B) How did you observe and implement appropriate actions to promote healthy living
and to prevent illness and accidents?
(15C.) In general, how do you use appropriate first aid and safety procedures when
responding to emergencies.
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(15D) How do you assist individual(s) in scheduling, keeping, and following through on
all health appointments?
(15E) How do you assist individuals in completing personal care activities (hygiene,
grooming, etc…)?
(15F) How did you assist with identifying, securing, and using needed health
equipment and therapies (i.e., physical, occupational, speech, respiratory,
psychological)?
(15G) How do you assist individuals in implementing health and medical treatments?
(15H) How did you assist individuals to take an active role in their health care
decisions?
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Please provide an actual sample of the work you did to demonstrate your
competency in this area. Work samples can be in the form of videos (must be able
to be viewed by graders via private You Tube link, Google Drive, Dropbox, etc..),
documentation, pictures, diagrams, testimonials, etc…
Please insert your work sample here for Supporting Health and Wellness.
Please write a statement reflecting on your experience with this work sample and
describe what you learned.
Effective- 1/1/2014
© Ohio Alliance of Direct Support Professionals. All rights reserved.
Page 27 of 29
Statement of Portfolio Authenticity
Candidate:
Skill Mentor:
Candidates in the DSPATHS Credentialing Program must assure that the work they have
submitted in their portfolios is authored and compiled by the candidate only.
Additionally, Skill Mentors must provide assurance that they have seen the work and
believe it to be the candidate’s authentic work.
These assurances MUST be included in the portfolio.
I attest that I have completed the work included in my portfolio. I have not represented
any other person’s or organization’s work as my own.
_
_________________________________________
Name of Candidate
Date
_
____________
I have reviewed this candidate’s portfolio and to the best of my ability and knowledge
believe it to be the original work of this candidate.
_
_________________________________________
Name of Skill Mentor
Date
Effective- 1/1/2014
_
____________
© Ohio Alliance of Direct Support Professionals. All rights reserved.
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Candidacy Application for the Certificate of Initial Proficiency (CIP)
Candidate’s Name:
Date:
DSPATHS Region or Licensed Entity:
I meet the following requirements:
Maintenance of an acceptable BCII Check.
Completion of at least 1320 hours of work experience as a Direct Support Professional in
the field or Intellectual and Developmental Disabilities.
Completion of the 60 hours of classroom instruction in the Certificate of Initial
Proficiency (CIP) and 40 hours of related instruction through the Candidate Workbook.
Completion of all requirements of the Certificate of Initial Proficiency (CIP) Portfolio.
I give the Ohio Alliance of Direct Support Professionals (OADSP) permission to utilize my
portfolio for teaching purposes, which may include but may not be limited to, posting all or
portions of it on the www.oadsp.org website.
Yes
No
I give the Ohio Alliance of Direct Support Professionals (OADSP) permission to include my
name on a list of Direct Support Professionals who have earned the Certificate of Initial
Proficiency (CIP) that will be published on the www.oadsp.org website.
Yes
No
Name of DSPATHS Candidate: _
Effective- 1/1/2014
_____________________ Date:
_________
© Ohio Alliance of Direct Support Professionals. All rights reserved.
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