In addition to the information required by Plc 304.03 and the documentation required by Plc 304.04, an applicant for voluntary certification as a CHW shall provide the following:

1. (a) If qualified based on work experience, the following information for each position held at which qualifying tasks were performed:

   1. (1) The name and address of the organization at which or for which the qualifying duties were undertaken;
   2. (2) The month and year when the work was started and when the work ended;
   3. (3) The total hours spent engaged in qualifying duties;
   4. (4) The specific qualifying duties undertaken; and
   5. (5) The name, daytime telephone number, and position held of an individual who can verify the information required by (1) through (4), above; and

2. (b) If qualified based on training:

   1. (1) The following information for each organization that provided the training:

      1. a. Name, address, telephone number, and email address; and
      2. b. Date training started and date training completed; and
   2. (2) A copy of the training certificate issued at the completion of the training.

Source. #14388, eff 10-24-25, EXPIRES: 10-24-35