Fillable Printable Dodd-1141 Training Approval Form
Fillable Printable Dodd-1141 Training Approval Form
Dodd-1141 Training Approval Form
Ohio Department of Developmental Disabilities
Application for Training Approval
for Continuing Professional Development Units
Before completing this form, please read instructi ons on reverse side. Please type or print form.
Applicant Information:
Applicant’s Resident County or County Board: ---------------------------------------------------------------------
Name of Individual Applying for Approval: ____________________________________________ Business Phone: ______________________
Email Address for Individual Applying for Approval: ___________________________________________________________________________
Applicant's Title/Position: ___________________________________ Applicant's Employer: ______________________________________
Applicant's Business Address: ____________________________________________________________________________________________
Training Information:
Training Topic/Title: ____________________________________________________________________________________________________
Training Location: ______________________________________________________________________________________________________
Training Date: _________________________________________________ Is training ongoing? Yes No
Instructor's Name: ___________________________________________ Instructor's Position: ________________________________________
Attendance Verifiers:
Name Position/Agency Signature (Required for Processing)
Comments: (Use reverse side if more space is needed.)
Type of Approval Requested: Approval/Disapproval:
(For DODD use only)
Type of
Registration/Certification
Units
Requested
Units
Approved
Disapproval
Code
Adult Services/Day Habilitation
Early Intervention
Investigative Agent*
Service and Support
Administration
Superintendent
County Board Members
*For Investigative Agency CPD applications only: Request for Dou ble CPD Units for the certified Investigative Agent conducting the CP D
training. List trainers to receive double units: _________________________________________________________________________________
Signature of Individual Applying for Approval: Signature of DODD Designee:
______________________________________________ _______________________________________
Date: _______________________________ Date: __________________________
DODD-1141 (03/2014)
(Please turn over)
Disapproval Codes:
I = Inappropriate Content
L= Lacks Detailed Agenda
N = No Timeline Provided
P = Post Training Request
O = Other (See Comments)
Approval Number
Ohio Department of Developmental Disabilities
Application for Training Approval
for Continuing Professional Development Units
Instructions:
1. This application must be completed and submitted prior to the beginning of the training. The
original-signed application must be received by DODD on or prior to the day of training;
training is not approved retroactively.
2. Failure to properly complete this form or to include supporting documents will result in
processing delay.
3. An agenda or syllabus that identifies topics, timelines, and objectives of the training must be
submitted with this form. The instructor's vita is not required.
4. Training must be relevant to the duties that match the type of registration/certification approval
requested.
5. A minimum of 50 minutes is required for one continuing professional development unit.
Approval will not be granted for partial units.
6. A copy of this form will be returned to the applicant with approval/disapproval noted.
7. Training participants must attend the entire session as described in the agenda or syllabus to
receive continuing professional development units.
8. Training instructors are responsible for maintaining records to sufficiently document
attendance by participants.
9. Attendance verifiers must verify attendance at the conclusion of the training session.
10. Training participants are responsible for securing verification of attendance at the conclusion of
training.
11. Ongoing Training refers to the same Training Topic/Title, Syllabus/Agenda, Timelines, and
Agenda listed in the application being offered repeat edly in the future by the same instructor(s)
and same Attendance Verifier(s). This application for CPD Units would apply to those trainings
as well. Checking “Yes” will allow this application to apply to these future trainings. Checking
“No” indicates that this is a one-time training.
12. Email this completed application and supporting documents
Additional Comments:
DODD-1141 (03/2014)
