Report Form Documenting Hours of Experience as an Alcohol and Drug Counselor

Alc 316.05 Report Form Documenting Hours of Experience as an Alcohol and Drug Counselor. The report form documenting hours of experience as a licensed alcohol and drug counselor or master licensed alcohol and drug counselor shall require: (a) The applicant’s full name; (b) The date the form was completed; (c) The information detailed in (d) below to be reported separately for each site of the applicant’s paid work experience for the previous 10 years, listed in sequential order; (d) The provision of the following information: (1) The applicant’s job title; (2) The dates of employment; (3) The duties performed by the applicant; (4) The percentage of the applicant’s time spent in alcohol or drug abuse counseling; (5) Whether the job was full time, part time or, if neither, an explanation of the structure of employment; (6) The hours worked per week; (7) The employer’s name; (8) The employer’s address; (9) The employer’s telephone; (10) The applicant’s supervisor’s name; and (11) The total number of hours of experience earned at this job site. Source. #12001, eff 10-13-16