 |
|
This tool kit provides all necessary forms, websites,and documents to implement the Standards for Licensure/Certification of Alcohol and/or other |
|
| R03-201 A | |
 |
Kansas business entity search |
 |
Sample Non-Profit Articles of Incorporation |
 |
Refer to Definitions (35) Proprietor |
| R03-201 B | |
|
Sample Board Meeting Minutes |
|
Kansas Malpractice Information |
| R03-201 C | |
|
|
|
|
|
Building a mission and vision statement |
|
How to create an organizational chart |
|
|
| R03-202 A | |
|
|
|
|
|
|
|
|
|
|
|
Federal Regulations on Confidentiality of Alcohol and Drug Abuse Client Records, 42 CFR, Part 2 |
|
Sample Drug Free Policy |
|
AAPS Ethics |
|
CDC Employee Accidents and Safety Issues Information |
|
CDC Infection Control Information |
|
Whistle Blowers Law |
|
|
|
|
|
|
|
Refer to Definitions (20) Employee |
|
Sample Employment Application |
|
Orientation Verification Statement |
|
Annual Performance Appraisal |
| R03-202 D | |
|
|
|
AAPS Credentialed Counselor - KAAP |
|
Refer to Definitions (47) Staff member |
|
Sample Staff Reference Check Request |
| Refer to Section 3 Clinical Program staffing | |
| R03-202 E | |
|
Confidentiality Verification Statement for Students, Interns and-or Volunteers |
| R03-202 F | |
|
|
|
|
|
|
| R03-203 B | |
|
AAPS Notification Change Form REMOVED |
 |
An example of making reasonable accommodations in program policies, practices and procedure to avoid discrimination on the basis of disability as defined in the ADA 1990 is a program has a client with limited mobility and the program has no elevator or ramp to accommodate client, the program would refer the client to another program. |
|
|
| R03-203 C | |
|
|
|
Example Policy and Procedure |
|
Refer to Definitions (13) Crisis Intervention |
|
Examples of crisis intervention services include after hour services, medical, mental, and legal/law enforcement. |
| R03-203 E | |
|
|
|
|
|
Incident Form |
|
Drill Records |
|
Approved Standards 1/5/07 |
| R03-203 F | |
|
U. S. Equal Employment Opportunity Commission |
| R03-203 G | |
|
SRS Appeals Statute |
|
SRS Appeals Process |
|
AAPS Contact Information |
|
|
| R03-203 J | |
|
NIDA Clinical Trials Committee Information |
| R03-301 A | |
|
CEUs Tracking |
|
AAPS Ethics |
|
AAPS Counselor Information Form |
| R03-301 B | |
|
Counselor Assistant Supervision Log |
| R03-301 C | |
|
AAPS Ethics |
| R03-302 A | |
|
Behavioral Sciences Regulatory Board |
|
AAPS Approved Colleges and Universities |
|
Counselor Assistant Supervisory Plan-Agreement |
| R03-303 A | |
|
|
| R03-303 B | |
|
CEUs Tracking |
|
Renewal Application |
| R03-303 G | |
|
AAPS Code of Ethics |
| R03-303 I | |
|
K.S.A. 75-3306 |
| R03-401 A | |
|
|
|
Risk Management |
|
Workplace Safety and Health |
| R03-401 B | |
| Refer to R03-401 A 1 and R03-401 A 2 | |
|
AAPS Code of Ethics |
| R03-401 C & D | |
|
Incident Form |
| R03-402 A | |
|
|
| R03-402 B | |
|
Client survey |
| R03-501 A | |
|
Examples of how to make program information known to the public could include program flyers, brochures, yellow page advertisements, and/or internet |
| R03-501 B | |
|
Examples of affiliated providers with whom the licensee has an agreement for services offered could include physicians, psychologists, labs, medical care, etc. |
| R03-502 A | |
|
American Red Cross |
|
|
|
Emergency Preparedness & Response |
|
Emergency Preparedness Plan |
| R03-502 B | |
|
|
|
|
| R03-502 C | |
|
|
|
|
| *Check your local municipal fire and safety inspection agency. | |
|
|
|
|
|
Infectious Disease Information/Publications |
| R03-502 D | |
|
Drill log |
| R03-502 E | |
|
|
| R03-503 A | |
|
|
|
|
| R03-503 B | |
|
Dieticians / Nutritionist |
| R03-504 A | |
|
Transportation Agreement |
| R03-504 B | |
|
Driving Records |
| R03-601 A | |
|
|
| R03-601 B | |
|
Residential Client Rights Requirements |
| R03-601 C | |
|
Acknowledgment Form |
| R03-602 A | |
|
|
|
|
| R03-602 B | |
|
Federal Confidentiality Laws |
|
Statute for notifying parent |
| R03-602 C | |
|
An example of when the release of information should be obtained in a language understood by the individual signing the written permission form is if a client understands or reads Spanish then the release needs to be in Spanish. |
| R03-602 D | |
|
Sample Release Forms |
|
Statute for notifying parent |
| R03-603 B | |
|
Refer to Definitions (3) Admission |
|
|
|
Referral Log |
|
Probate Code for Involuntary Commits 59-29b45 through 84 |
|
Treatment Contract |
|
Examples of information or records provided by or obtained from another individual, agency, program or entity could include lab reports, medical reports, court orders, probation reports, discharge summary, or information from another treatment provider. |
|
Client Record Request and Release Form |
|
Examples of documentation of telephone, written, or face to face contact with the client or another individual that relates to the client's health, safety, welfare or treatment could include communication with medical, legal, social services, etc. and needs to include date, time and details of information discussed/shared. |
|
|
|
|
|
|
|
Center for Disease Control and Prevention |
|
Sample Medical/Nursing Assessment |
| R03-604 A | |
| Refer to Definitions (16) Discharge Planning | |
| R03-605 A | |
|
Screening and Assessment Instruments |
|
Examples include the SASSI, MAST, CAGE, etc. |
| R03-605 C | |
|
Sample Assessment Form |
|
Five year employment history includes sporadic employment history, unemployment, disability, incarceration and homemaker. Under the age of 18 can include education, if applicable. |
|
A support system may be individuals and services that support the client in recovery. |
|
Examples of collateral sources could include police, probation, social services, medical etc. |
| R03-606 B | |
|
Sample Treatment Plan |
|
Individualized is based on unique characteristics, wants, needs and abilities |
|
Long term goals are defined as the client's life goals, six months and beyond treatment. |
|
Short term goals are defined as the goals that the client will accomplish in treatment. They are Specific, Measurable, Achievable, Relevant, and Time-framed (SMART). |
|
Tasks are activities, actions, behaviors the client must do or take in order to reach the goal. These are objective and observable and become the basis upon which progress notes are written. |
|
Community Resources/Referrals are those people/places/things that are external from your program that supports the person in their recovery. For example parents, foster parents, church, probation, teachers, doctor, twelve step meetings, etc. |
| R03-606 D | |
|
Sample Treatment Plan Update Form |
| R03-608 B | |
|
Sample Discharge Summary |
| R03-609 A | |
|
Sample Medication Form |
| R03-609 B | |
|
Refer to Definitions (40) Self Administration |
| R03-609 C | |
|
Drug Identification |
|
|
| R03-609 F | |
|
Controlled Substances |
| R03-701 C | |
|
Sample Referral Log |
| R03-702 B | |
|
Refer to Definitions (36) Qualified Staff |
| R03-702 C | |
|
Refer to Definitions (12) Counseling |
|
Refer to Definitions (46) Substance Abuse Education Services |
|
Refer to Definitions (36) Qualified Staff |
| R03-703 C | |
|
Refer to Definitions (12) Counseling |
| R03-704 B | |
|
Refer to Definitions (36) Qualified Staff |
| R03-704 C | |
|
Refer to Definitions (12) Counseling |
| R03-705 C | |
|
Refer to Definitions (20) Employees |
| R03-705 D | |
|
Refer to Definitions (12) Counseling |
| R03-708 B | |
|
Refer to Definitions (36) Qualified Staff |
| R03-708 C | |
|
Refer to Definitions (20) Employees |
| R03-708 D | |
|
American Red Cross |
| R03-708 E | |
|
Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) |
| R03-709 B | |
|
Refer to Definitions (36) Qualified Staff |
| R03-709 E | |
|
Refer to Definitions (12) Counseling |
| R03-710 B | |
|
Sample Medical/Nursing Assessment |
| R03-711 C | |
|
Drug Enforcement Agency |
|
|
| R03-711 O | |
|
Sample Exception Form |
| R03-712 C | |
|
Sample Pre-Screen Form |
| R03-713 F | |
|
List of Approved Tools |
| R03-714 C | |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| R03-714 D | |
| None available at this time | |