The report form documenting hours of experience as a licensed alcohol and drug counselor or master licensed alcohol and drug counselor shall require:

1. (a) The applicant’s full name;
2. (b) The date the form was completed;
3. (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;

4. (d) The provision of the following information:

   1. (1) The applicant’s job title;
   2. (2) The dates of employment;
   3. (3) The duties performed by the applicant;
   4. (4) The percentage of the applicant’s time spent in alcohol or drug abuse counseling;
   5. (5) Whether the job was full time, part time or, if neither, an explanation of the structure of employment;
   6. (6) The hours worked per week;
   7. (7) The employer’s name;
   8. (8) The employer’s address;
   9. (9) The employer’s telephone;
   10. (10) The applicant’s supervisor’s name; and
   11. (11) The total number of hours of experience earned at this job site.

Source. #12001, eff 10-13-16