Certification of Completion
The University of the State of New York
The State Education Department (Coursework/Training in Identification and Reporting of
Child Abuse and Maltreatment)
Updated 2022 to include recent amendments to Social Services Law §413 requiring the addition of Adverse Childhood Experiences and Trauma,
Implicit Bias, and Identification of Child Abuse virtually.
Section I: Trainee Information
Trainee Instructions: Make sure Section I is complete. When you have received this form with a completed Section II from the coursework or training
provider, submit this completed form to the appropriate address at the end of this form. Keep a copy of this form for your records.
Important Note: Only this completed form can be accepted as sufficient documentation by the Department that you have completed the required coursework or
training. It is your responsibility to ensure all of the appropriate documentation has been received by the Department (especially in the case of providers
that submit certifications to the Department electronically). Failure to do so will result in not receiving credit for completion of this coursework or training.
1. Social Security Number 2. Birth Date Month Day Year
(Leave this blank if you do not have a U.S. Social Security Number)
3. Print Name Last
First 5. Telephone/Email Address
Middle Daytime Phone
Home or Business
Licensee business address, phone and email address are public information. Failure to indicate business
or home on this form for each item will deem it public information.
4. Mailing Address Home or Business Area Code Phone
(You must notify the Department within 30 days of any address or name changes)
Email Address (please print clearly)
Line 1 Home or Business
Line 2
Line 3
6. New York State DMV ID Number
City (Driver or Non-Driver ID)
State ZIP Code
(Leave this blank if you do not have a
Country/ New York State DMV ID Number)
Province
7. If you currently hold or are applying for professional licensure, permit or a teacher certification in New York State, list in what profession(s)
or certificate title(s) here:
8. I hereby attest that the information provided in Section I of this form is true, complete and correct.
Signature Date
Section II: Certification by Approved Provider
Provider Instructions: Complete Section II. Submit this form to the trainee listed on this form within ten calender days of the completion of the coursework or
training. Important Note: As the provider of this coursework or training, you MUST retain a copy of the certification of completion provided to this trainee in your
files for not less than five years from the date the course was completed.
Approved Provider Name
Identification Number Dates of coursework/training
Pursuant to Chapter 544 of the Laws of 1988, I certify that the trainee named above has completed the required coursework or training
regarding the identification an reporting of child abuse and maltreatment.
Signature of Authorized Certifying Officer Date
If this certification of completion is being submitted in support of an application for New York State Licensure or Permit, Return Directly to: New York
State Education Department, Office of the Professions, Division of Professional Licensing Services, [Be sure to give name of profession], 89 Washington
Avenue, Albany, NY 12234-1000.
If this certification of completion is being submitted in support of an application for reregistration of a New York State license: Make sure to include
this completed form with your reregistration application.
If this certification of completion is being submitted in support of an application for New York State Teacher Certification, Return Directly to: New
York State Education Department, Office of Teaching, 89 Washington Avenue, Albany, NY 12234-1000.
Certification of Completion Form, Revised 8/23
