RESIDENCY RENEWAL OR PROFESSIONAL EDUCATIONAL

4095 Req. (Rev. 7/16) Page 1 of 1

RESIDENCY RENEWAL OR PROFESSIONAL

EDUCATIONAL STAFF ASSOCIATE

CERTIFICATION REQUIREMENTS

School Psychologist

In Washington, certain specialists who serve in the K-12 schools are certified as educational staff associates (ESAs). This packet is for

the above-mentioned roles only. For ESA certification as a school nurse, school occupational therapist, school physical therapist,

school social worker, or school speech language pathologist or audiologist, or school counselor, please visit our website at

www.k12.wa.us/certification/ESA/NotCertified.aspx

REQUIREMENTS:

RESIDENCY ESA RENEWAL CERTIFICATE

NOTE: We recommend that individuals who are not employed pursue renewal ONLY when they are ready to serve in the role in

Washington to ensure the validity will allow time to complete the requirements to obtain the professional ESA certificate.

Two-year renewal options:

 School psychologists in the process of obtaining Nationally Certified School Psychologist (NCSP) certification from the

National Association of School Psychologists (NASP) may apply for a one-time two-year renewal with verification of NCSP

submission. Additionally, individuals with expiring certificates in 2014, 2015, 2016, or 2017, may apply for a second two-year

renewal with verification of NCSP submission.

 School psychologists with residency ESA certificates dated to expire June 30, 2013, 2014, 2015, 2016, or 2017, may apply

until June 30, 2016, for a two-year renewal. These individuals may apply for a second two-year renewal until June 30, 2018.\

Five-year renewal option:

 Individuals who hold, or have held, a residency ESA school psychologist certificate who are not employed in the role may

have their certificate(s) renewed for five years with completion of one of the following options:

o 15 quarter/10 semester credits of college course work from an accredited institution of higher education directly

related to the current performance-based standards as defined in WAC 181-78A 270f5) since the issuance of the

residency ESA certificate for the role.

o 150 clock hours directly related to the performance-based standards as defined in WAC 181-78A-270(5) since the

issuance of the residency ESA certificate.

PROFESSIONAL CERTIFICATE (Valid for five years)

All must be met:

 Hold a Nationally Certified School Psychologist (NCSP) certificate issued by the National Association of School

Psychologists (NASP).

 Issues of Abuse: The issues of abuse course or course work must include information related to identification of physical,

emotional, sexual, and substance abuse; the impact on learning and behavior; the responsibilities of an ESA to report abuse

or to provide assistance to victimized children; and methods of teaching about abuse and its prevention.

 Suicide Prevention Training (per RCW 28A.410.226): The candidate shall attest to the completion of a Professional

Educator Standards Board approved suicide prevention training (within the previous five years), Effective July 1, 2015. Please

visit http://www.pesb.wa.gov/educators/professional-certificate/education-staff-associate for current information and course

listing.

Application Instructions (Rev. /1)

APPLICATION INSTRUCTIONS

Only COMPLETE applications (all items except your fingerprint cards) will be accepted for processing by the

Office of Superintendent of Public Instruction.

If the background check reveals a criminal record, or if you answer “yes” on the character and fitness supplement

(Form SPI/CERT 4020B), your application materials will be forwarded to the Office of Professional Practices for review.

This may delay the certification process for several months. The Professional Certification office cannot act on your

application materials until clearance is received from the Office of Professional Practices.

Fingerprints.

You may select one of the following options to complete the fingerprint process:

A. You may utilize the live scan fingerprinting process in person at one of the ESD locations. This process does

not require a fingerprint card and is subject to an additional processing fee. Please contact the ESD of your

choice for details.

If your fingerprints are worn and not easily discernible the State Patrol recommends you have your prints

processed by the ink and roll method using the fingerprint card and instruction sheet which can be obtained

from our office. Once you have the card and instructions, this may be completed by contacting a law

enforcement agency that will fingerprint applicants for non-criminal background checks. Please check with the

agency for additional processing fees. Some ESD offices may provide the ink and roll method in addition to

the electronic Live Scan.

It is your responsibility to collect the items needed for evaluation for certification and submit them in one envelope to

the OSPI Office.

All fees are non-refundable.

Washington State law requires that any applicant who does not hold a valid Washington certificate at the time of

application must be fingerprinted for a state and national background check. Since this could delay the application, we

urge you to initiate this process as soon as possible.

4095 Chklst (Rev. 7/16)

RESIDENCY RENEWAL OR PROFESSIONAL

EDUCATIONAL STAFF ASSOCIATE

CERTIFICATION APPLICATION CHECKLIST

FORM SPI/CERT 4095A APPLICATION FOR WASHINGTON STATE RESIDENCY RENEWAL OR PROFESSIONAL

ESA CERTIFICATION

FEE

I am enclosing a COMPLETE Washington ESA certification application.

Signature Date

SEND YOUR COMPLETE APPLICATION PACKET AND FEE TO OSPI, FISCAL OFFICE, P.O. BOX 47200, OLYMPIA,

WA 98504-7200.

School Psychologist ONLY

RENEWAL:

In addition to the certification fee, a $39.00 OSPI processing fee per certificate action are required. Please select the

appropriate box for the certificate(s) you are requesting and attach your check in the amount indicated made out to OSPI

- Fiscal Office.

FORM SPI/CERT 4020B CHARACTER AND FITNESS SUPPLEMENT

FORM SPI/CERT 4020C VERIFICATION OF GOOD STANDING FOR CERTIFICATES HELD IN OTHER STATES

FINGERPRINT BACKGROUND

CHECK

Please indicate the date submitted:

If you do not hold a valid Washington certificate, the following are also required:

PROFESSIONAL:

OFFICIAL TRANSCRIPTS Verifying completion of 15 quarter/10 semester credits of study since

issuance of residency ESA certificate (for five-year renewal, if eligible), or

Copy of valid Nationally Certified School Psychologist (NCSP) certificate.

Five-year Residency ESA Renewal only: $25 + $39 (OSPI) = $64

Five-year Residency ESA Renewal & Substitute ESA: $25 + $15 + $78 (OSPI) = $118

Professional ESA only: $25 + $39 (OSPI) = $64

Professional ESA & Substitute ESA: $25 + $15 + $78 (OSPI) = $118

Verification of Nationally Certified School Psychologist (NCSP) assessment submission.

Two-year Residency ESA Renewal only: $10 + $39 = $49

Two-year Residency ESA Renewal & Substitute ESA: $10+ $15 + $78 (OSPI) = $103

ISSUES OF ABUSE Complete Form 4095A, page 1, question 13.

SUICIDE PREVENTION Complete Form 4095A, page 1, question 14.

OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION

Professional Certification

Old Capitol Building, PO BOX 47200

OLYMPIA WA 98504-7200

(360) 725-6400 TTY (360) 664-3631

Web Site: http:/ /www.k12.wa.us/certification/

E-Mail: [email protected]

APPLICATION FOR WASHINGTON STATE

EDUCATIONAL STAFF ASSOCIATE CERTIFICATION

ESA role requested:

School Psychologist

Certificate requested:

Substitute

Each certificate (role) requested requires a separate fee payment.

NAME LAST FIRST MIDDLE1.

ADDRESS2.

CITY/STATE/ZIP

TELEPHONE5.

BUSINESS HOME

( ) ( )

MAIDEN/FORMER NAME

DATE OF BIRTH

SOCIAL SECURITY NO. (OPTIONAL)

FORM SPI/CERT 4095A (Rev. 7/16)

What is your Washington educational certificate number?

YES

NO8. Have you held an educational certificate in another state? If yes, list all such states here.

Complete Form SPI/CERT 4020C if you

do not hold a currently valid Washington

certificate.

Page 1 of 2

Please complete the following questions and sign the affidavit.

E-MAIL

Professional

Please provide your full, legal name.

Five-year Residency Renewal

9. From what accredited college or university did you receive your master's degree?

CLASS TITLE

DATE WHERE COMPLETED

DATE

10.

If you are applying for a five-year residency ESA renewal, you must verify that you are not employed in the role.

am am NOT employed in the role of school psychologist and am enclosing official transcripts verifying completion of the

required course work for renewal.

Two-year Residency Renewal

Your residency ESA certificate expired/expires on June 30, 2013, 2014, 2015, 2016, or 2017 and you are applying for your first

two-year renewal.

11.

YES N/A

If you are applying for the professional ESA certificate, a course or course work relating to issues of abuse is required. Indicate class

title, date, and where (college, university, SD, etc.) requirement was completed.

13.

Your first two-year residency ESA renewal expired/expires on June 30, 2013, 2014, 2015, 2016, or 2017 and you are applying for your

second/final two-year renewal.

12.

YES

N/A

CLASS TITLE

DATE COMPLETED PROVIDER

Indicate class title, date, and provider of the completed suicide prevention training.

If you are applying for the professional ESA certificate, completion of a Professional Educator Standards Board approved suicide

prevention training within the last five years is required. (For details and current training listing, please visit

www.pesb.wa/gov/educators/professional-certificate/education-staff-associate.)

14.

FORM SPI/CERT 4095A (Rev. 7/16)

Page 2 of 2

Five-Year Residency ESA Renewal ONLY: List the credits you completed since issuance of your residency ESA certificate in the

space below and provide the additional information requested. Official transcripts (those with the college or university seal) must

be submitted with your application.

15.

Institution

Dates Attended

Course Title

Location

City/State

Post BA Credits Earned

From

Semester Quarter

THIS FORM MUST BE INCLUDED IN THE APPLICATION PACKET.

AFFIDAVIT

I, _________________________________, certify (or declare) under penalty of perjury under the laws of the state of

Washington that the foregoing and all information included in this application is true and correct. If the answers to any question

on the application or the character and fitness supplement change prior to my being granted certification, I must immediately

notify Professional Certification at OSPI.

Signature Date City/State

ATTACH ADDITIONAL SHEETS IF NECESSARY

FORM SPI/CERT 4020B (Rev. 9/15)

OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION

Professional Certification

Office of Professional Practices

Old Capitol Building, PO BOX 47200

OLYMPIA WA 98504-7200

OPP (360) 725-6130 TTY (360) 664-3631

Web Site: http:/ /www.k12.wa.us/certification

E-Mail: [email protected]

CHARACTER AND FITNESS SUPPLEMENT

Please complete the following questions carefully and completely before providing information and signing the affidavit. Any

falsification or deliberate misrepresentation, including omission of a material fact, in completion of this application can be

grounds for denial of certification, or in the case of a certificate holder, reprimand, suspension, or revocation of the

educational certificate, credential, or license.

ALL REQUIRED DOCUMENTATION REQUESTED BELOW MUST ACCOMPANY THIS FORM. ALL QUESTIONS MUST BE

ANSWERED. IF ADDITIONAL SPACE IS NEEDED, ATTACH ON A SEPARATE SHEET OF PAPER.

SECTION I - PERSONAL INFORMATION (please print or type)

NAME LAST FIRST MIDDLE

MAIDEN NAME

ADDRESS

CITY/STATE/ZIP

DATE OF BIRTH

TELEPHONE

SOCIAL SECURITY NO. (OPTIONAL)

BUSINESS: HOME:

( ) ( )

8. Please list all former names you have used and approximate dates of use. (If more than three, list on separate sheet of paper.)

Date

SECTION II - PROFESSIONAL FITNESS

Yes

Have you ever held or do you currently hold a Washington education certificate?

Have you ever held or do you currently hold any education certificate, credential or license authorizing service in

the public/private schools in another state, province, territory, or country? If “yes,” list the states, provinces,

territories, and/or countries:

Are you currently or have you ever been the subject of any certificate or licensing investigation or inquiry by any

certification or licensing agency for allegations of misconduct? If “yes,” on a separate sheet of paper, list the

agency, including complete address and telephone number as well as the purpose of the investigation or inquiry.

If you answer “yes” to questions 4 through 11 (Section II), on a separate sheet of paper, give a complete explanation,

including duties, circumstances, and supporting documentation.

Have you ever had any adverse action taken on any certificate or license? (Adverse action includes letters of

warning, reprimands, suspensions [including stayed], revocations, voluntary surrenders, or voidance.)

Have you ever been denied, or otherwise rejected for cause, an education certificate, credential, or license?

Have you ever withdrawn an application for any education certificate, credential, or license?

Have you ever practiced in any educational position in a public school for which you did not hold the appropriate

valid educational certificate, credential, or license for that position?

Have you ever been dismissed, discharged, or fired from any employment position involving children or

dependent adults? (Do not include RIFs)

Have you ever resigned from or otherwise left any employment (e.g., settlement agreement) while allegations of

misconduct were pending?

Page 1 of 4

E-MAIL7.

FORM SPI/CERT 4020B (Rev. 9/15)

SECTION III - CRIMINAL HISTORY

Yes

In the last 10 years, have you ever been arrested for any crime or violation of the law? (Do NOT include Minor in

Possession [MIP]/Minor in Consumption [MIC] occurring more than 2 years ago or Driving Under Influence

[DUI/DWI] occurring more than 5 years ago.) (Note: For “yes” responses to 1, 2, 3, even if your case was

dismissed or your record was sealed you must answer this question in the affirmative.) You need not list traffic

violations for which a fine or forfeiture of less than $300 was imposed.

In the last 10 years, have you ever been fingerprinted as a result of any arrest for any crime or violation of the law?

In the last 10 years, have you ever been convicted of any crime or violation of any law? (Note: For the purpose of

this question “convicted” includes [1] all instances in which a plea of guilty or nolo contendere is the basis of

conviction, [2] all proceedings in which a sentence has been suspended or deferred, [3] or bail forfeiture.) You

need not list traffic violations or fines for which a fine or forfeiture of less than $300 was imposed.

Have you ever been convicted of any felony crime?

Do you currently have any outstanding criminal charges or warrants of arrest pending against you? This would

include Washington State, any other state, province, territory, and/or country.

Have you ever been or are you presently under investigation in any jurisdiction for possible criminal charges? If

your answer is “yes,” identify agency and location (street address, city, state) and the circumstances or details

relating to the investigation on a separate piece of paper.

If you answer “yes” to any question (Section IV), provide a written explanation on a separate sheet of paper:

Have you ever exhibited any behavior or conduct which might negatively impact your ability to serve in a role which

requires a certificate, credential, or license?

In the past 10 years, have you ever engaged in any conduct which resulted in the damage or destruction of

property? (For purposes of questions 2 and 3, property includes both real and personal property owned by you or

another. Do not list damages done as the result of an automobile accident.)

In the last 10 years, have you ever threatened to damage or destroy property?

Have you ever engaged in any conduct which resulted in the physical injury or harm of any person(s)? (Do not list

injury or harm caused as the result of duties performed due to a job assignment such as police officer, armed

forces member, or athlete.)

Have you ever threatened to do physical injury or harm to any person(s)? (Do not list threats issued as the result of

duties performed due to a job assignment such as police officer, armed forces member, or athlete.)

Page 2 of 4

Yes No

10.

11.

Have you ever been disciplined by a past or present employer because of allegations of misconduct?

Are you currently or have you ever been the subject of any investigation or inquiry by an employer because of

allegations of misconduct?

If you answer “yes” to any of the questions 1–5 (Section III), please provide the following:

A detailed statement including what occurred, the nature of the offense, charge or warrant.

The name and address of the arresting agency.

If a court was involved, the name and address of the court.

The date of the arrest.

The final disposition, if any.

SECTION IV - FITNESS

Yes No

NOTE: For questions 1, 2, 3, DO NOT include minor in possession (MIP)/minor in consumption (MIC) occurring more than 2 years

ago or driving under influence (DUI) occurring more than 5 years ago.

A. On a separate sheet of paper state the following:

If the arrest was driving related, provide a copy of a current and complete 5-year driving abstract.

If a court was involved, provide a copy of the court docket (can be obtained at the court in which the charge[s] were filed).B.

If a court was involved, provide the sentence and judgment (can be obtained at the court in which the charge[s] were filed).

Provide a copy of the complete arresting officer’s report.C.

FORM SPI/CERT 4020B (Rev. 9/15)

SECTION IV - FITNESS

Yes

Do you have a medical condition which in any way impairs or limits your ability to serve in a certificated role

with reasonable skill and safety?

If you use chemical substance(s), does this use in any way impair or limit your ability to serve in a certificated

role with reasonable skill and safety?

If you disclosed a “yes” answer to questions 6 or 7 above, are the limitations or impairments caused by your

medical condition(s) or substance abuse reduced or ameliorated because you receive ongoing treatment (with

or without medications) or participate in a monitoring program? Please explain on a separate sheet of paper

and provide the name, address, and telephone number of the program.

Do you currently use illegal drugs?

Have you used illegal drugs in the last year?

If you disclosed a “yes” answer to question 9 above, have you successfully completed or are you participating

in a supervised rehabilitation program? Please explain on a separate sheet of paper and provide the name,

address, and telephone number of the program.

List three individuals, not related to you, who will serve as character references.

10.

11.

12.

13.

Have you ever been found in any dependency or domestic relation matter to have sexually assaulted or

exploited any minor?

Have you ever been found in any dependency or domestic relation matter to have physically abused any

person?

Are you currently in default status on any educational loan or scholarship? (Do not include loans that are

currently in a compliant deferment status.)

Are you currently in non-compliance with a support order?

Page 3 of 4

SECTION V - CHARACTER REFERENCES

Yes

N/A

If you answer “yes” to questions 10 or 11, attach copies of any court orders entered in the proceeding.

NAME

MAILING ADDRESS

TELEPHONE NUMBER

( )

CITY/STATE/ZIP

NAME

MAILING ADDRESS

NAME

MAILING ADDRESS

TELEPHONE NUMBER

( )

CITY/STATE/ZIP

TELEPHONE NUMBER

( )

CITY/STATE/ZIP

N/A

If you answer “yes” to questions 12 or 13, and a repayment agreement has been established, attach copies of the

repayment agreement from the appropriate agency.

Yes

* ATTENTION *

Please complete the appropriate sections on the next page (pg. 4 of 4).

E-MAIL ADDRESS (OPTIONAL)

FORM SPI/CERT 4020B (Rev. 9/15)

Page 4 of 4

AFFIDAVIT

I, ___________________________________ certify (or declare) under the penalty of perjury under the laws of the state of

Washington that the foregoing and all information included in the application is true and correct.

If the information provided or answer(s) to any question on the application or character and fitness supplement changes prior to my

being granted certification, I must immediately notify the Office of Professional Practices and my college/university if I am a

college/university candidate.

I understand I must answer this application truthfully and completely. Any falsification or deliberate misrepresentation, including

omission of a material fact, in completion of this application can be grounds for denial of certification, or in the case of a certificate

holder, reprimand, suspension, or revocation of the educational certificate, credential, or license.

SIGNATURE DATE CITY/STATE

ALL APPLICANTS MUST COMPLETE THE AFFIDAVIT

AFFIDAVIT

I hereby authorize ___________________________________________ to release, orally or in writing as may be requested,

(name of college/university)

all student records and other personally identifiable information to the Office of the Superintendent of Public Instruction

(OSPI) for the purpose of investigating and determining my eligibility for Washington State certification pursuant to

RCW 28A.410, WAC 181-86, and WAC 181-87, as now or hereafter amended

SIGNATURE OF APPLICANT DATE

COLLEGE/UNIVERSITY STUDENTS ONLY

Please also complete the release below:

FORM SPI/CERT 4020C (Rev. 9/15)

OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION

Professional Certification

Old Capitol Building, PO BOX 47200

OLYMPIA WA 98504-7200

(360) 725-6400 TTY (360) 664-3631 FAX (360) 586-0145

Web Site: http:/ /www.k12.wa.us/certification/

E-Mail: [email protected]

VERIFICATION OF GOOD STANDING FOR

CERTIFICATES HELD IN OTHER STATES

COMPLETE SECTION A ONLY, AND INCLUDE THIS FORM IN YOUR APPLICATION PACKET. DO NOT SEND THIS FORM TO

THE STATE(S) IN WHICH YOU HAVE BEEN CERTIFIED.

SECTION A

Carefully complete information in Section A only, indicating certificate type and number when possible.

TO BE COMPLETED BY APPLICANT

NAME LAST FIRST MIDDLE1. MAIDEN/FORMER NAME

ADDRESS2.

DATE OF BIRTH3.

SOCIAL SECURITY NO. (OPTIONAL)4.

TELEPHONE5.

CITY/STATE/ZIP

BUSINESS

HOME

( )

STATE

TYPE OF CERTIFICATION

CERTIFICATE NUMBER

I, _____________________________________________ certify (or declare) under penalty of perjury under the laws of the state of

Washington that the foregoing is true and correct. I hereby allow the above-mentioned state(s) to release the information concerning

my certificate to the Office of Superintendent of Public Instruction.

Signature Date

WASHINGTON STATE CERTIFICATION OFFICE WILL PROCESS THE REMAINDER OF THIS FORM (IF

NECESSARY)

SECTION B

The individual noted above holds or has held certification in your state. Washington Administrative Code requires that we have

a statement from you confirming that none of his/her certificates held in your state have been suspended, surrendered, or

revoked. DO NOT RETURN QUESTIONNAIRE TO APPLICANT.

I confirm that the above-named individual has never had a certificate suspended, surrendered, or revoked in this

state.

I confirm that the above-named individual has had a certificate suspended, surrendered, or revoked. I have

attached explanatory materials which fully disclose the reasons for such action. (Permission to provide this

information is granted in the center portion of this form.)

AGENCY DATE

ADDRESS

SIGNATURE

TITLE

E-MAIL