In signing the application I am affirming that I meet the pre-requisites for the training, and that I have read and understand the requirements to become an EPIC Trained Motivational Interviewing Trainer. (Electronic Signatures Acceptable and will be considered the equivalent of an actual signature) Date Applicant’s Signature Printed Name Please include the Supervisor Checklist and Approval with your application EPIC MI TRAINER APPLICATION SUPERVISOR CHECKLIST AND APPROVAL (To be completed by your immediate supervisor) Administrative supports are a critical aspect in developing quality trainers that maintain fidelity to MI as well as implementing the evidence-based practice in a sustainable way. Similarly, staff selection is also a critical element in sustaining practice and resources for your agency. Having you informed and involved in the process is important. Your input and approval is extremely valuable to EPIC and the implementation team as they consider the selection process and work to support the fidelity, sustainability and implementation of MI in your agency. According to the following scale, please rank those qualities that you feel the applicant possesses. 5 4 3 2 1 High Medium Low Willingness to accept constructive comments in order to improve skills. Comment: Ability and willingness to work as part of a team. Comment: Ability to adapt to a variety of situations and circumstances. Comment:
In signing the application I am affirming that I meet the pre-requisites for the training, and that I have read and understand the requirements to become an EPIC Trained Motivational Interviewing Trainer. (Electronic Signatures Acceptable and will be considered the equivalent of an actual signature) Applicant’s Signature Date Printed Name Please include the Supervisor Checklist and Approval with your application EPIC MI TRAINER APPLICATION SUPERVISOR CHECKLIST AND APPROVAL (To be completed by your immediate supervisor) Administrative supports are a critical aspect in developing quality trainers that maintain fidelity to MI as well as implementing the evidence-based practice in a sustainable way. Similarly, staff selection is also a critical element in sustaining practice and resources for your agency. Having you informed and involved in the process is important. Your input and approval is extremely valuable to EPIC and the implementation team as they consider the selection process and work to support the fidelity, sustainability and implementation of MI in your agency. According to the following scale, please rank those qualities that you feel the applicant possesses. 5 4 3 2 1 High Medium Low Willingness to accept constructive comments in order to improve skills. Comment: Ability and willingness to work as part of a team. Comment: Ability to adapt to a variety of situations and circumstances. Comment:
EPICTrainersApplication2016.docx