ADMS Renewal Application | Certified Disability Management Specialist (CDMS)

Certification of Disability Management Specialists Commission (CDMSC) ADMS Renewal Application

All information on this application must be filled, except where a signature is required. Applications without the fee will not be processed.

Name as you would like it to appear on the certificate

Previous Name if different from initial designation

Year of initial designation

Current certificate #

Address

City/Town

State/Province

ZIP/Postal Code

Check here if this is a new address.

Position/Title

Home Telephone

Work Telephone

E-mail Address

Once we receive this completed form, we will provide instructions on how to pay the ADMS renewal fee.

Continuing Education Summary:
To renew your designation, a minimum of 30 clock hours of approved continuing education must be completed. This would include a minimum of 12 hours in the focus areas shown in this guide, a minimum of 2 hours in ethics, and a maximum of 15 hours in the area of professional development.

Focus Areas (Domains)	CE Earned
I: Disability and Work Interruption Case Management
II: Workplace Intervention for Disability Prevention
III: Program Development, Management, and Evaluation
IV: Employment Leaves and Benefits Administration
V: Ethics
VI: Professional Development Areas
Total minimum of 30 (2 Ethics) required

Eligibility Documentation:

I attest that during the past three (3) years I have been actively and directly involved in disability management.

I have read the understood all provisions of the ADMS Code of Professional Conduct found in the ADMS Guide for Designation and Renewal

Answer the questions below by circling the appropriate response. If you answer YES to any questions, you MUST include an explanation and, if appropriate, a final decree.

Have you ever held a professional license or certification that was revoked, suspended, or YES NO voluntarily relinquished or been placed on probation by a professional licensure or credentialing body?

Provide a written explanation including whether your certification/license is now in good standing.

Have you ever been known by any given or surname other than those shown on the label attached to this application?

List other names with dates used and reasons for change in name in your explanation.

Have you ever been convicted of a felony?

Your explanation must state the facts in full, including date and location, nature of incident or proceeding, nature of original and any subsequent charges or accusations, case name and number, court, and status or disposition of the matter.

During the last seven (7) years, have you ever been convicted of violating any law or ordinance YES NO (except for minor traffic violations and/or convictions as a juvenile)?

Have you ever been convicted of violating any statute or ordinance dealing with sexual assault, YES NO abuse, molestation, indecent solicitation, obscenity, or similar acts of moral turpitude?

Applicant’s Signature

Sign above

Date