This document contains three pages: this page of instructions and two copies of your certificate.

If your name is incorrect on your certificate, or if you have changed your name since registering, please
contact us by email at help@violenceworkshop.com and we will update your name. You cannot change your
name yourself.
For all professions which involve working in a school:
Your certificate will be sent electronically to the State and should appear on your TEACH account within
a week. There is no need for you to send them anything. If you have not yet created a TEACH account, the
State will hold your certificate and automatically process it when you create your account.

For all licensing NOT related to the Education professions:

You must print, sign, and mail your certificate to:
New York State Education Department, Division of Professional Licensing Services
[Type or Print the name of your profession]
89 Washington Avenue, Albany, NY 12234
If you have completed the workshop in Identification and Reporting of Child Abuse and Neglect, and are
not sure how to fill in sections 5 and 6, you may leave them blank. Do not return any documents to us.
Mandated workshops are not the only item required in order to secure employment and get certified or
licensed in your profession. The document that we provide must be submitted to New York State along
with, or following, an official State application in addition to other supporting documents. If, and only if,
you are certain that you have already submitted your professional application to the State, mail your
certificate to the State. If you need an application, wish to apply online, or are unsure what other
requirements you must fulfill, visit the State's website at www.nysed.gov or call them directly at
1-518-474-3901.
If you are required to take a state-mandated workshop, it is likely that you will be working with children in
some context. When faced with a situation or you suspect a wrongdoing, don't hesitate. Please remember
that the safety of children may be at stake and that you can make a difference and save lives!

WWW.VIOLENCEWORKSHOP.COM
WWW.CHILDABUSEWORKSHOP.COM
WWW.AUTISMAUTISM.COM
If you found our course instructive, we would appreciate if you referred other people to our website. You
will get $5 for each person you refer to our websites. Just make sure that they enter your email address as the
referral source when they register. Referrals are processed and sent within 8-12 weeks.

The University of the State of New York

THE STATE EDUCATION DEPARTMENT

Certification of Completion

(Coursework/Training in Identification and Reporting of Child Abuse and Maltreatment)

Part A: Trainee Information

This form is all that you need as proof that you have completed your mandated training. For all professions which
involve working in a school, your certificate will be sent electronically to the State and should appear on your
TEACH account within a week. For all licensing not related to the the Education professions, sign and date the
form, and then send it to the state along with your license application. This form is just one requirement for
certification/licensing. Other requirements include the application, transcripts, and, in some cases, passing exams.
For an application and further details on certification/licensing, call 1 (518) 474-3901 or visit the New York State
Education Department at www.nysed.gov
1

SOCIAL SECURITY NUMBER:

PRINT YOUR FULL NAME EXACTLY AS IT CURRENTLY APPEARS ON NEW YORK STATE EDUCATION DEPARTMENT RECORDS

(Leave this blank if you do not have a U.S. Social Security Number)

Last

First
Middle

Organization

Line 1

City/State
Country

BIRTH DATE:

02/10/90

Tkach

Alessia
M

Medaille College

M AILING ADDRESS
Line 2

(You must notify the Department promptly of any address or name changes.)

978 Upper Kenilworth

Hamilton Ontario
Canada

Zip code

Complete information below if you hold, or are applying for

professional license(s) or a permit:

Name of Profession(s):

L8W2L3
6

Complete information below if you hold, or are applying for a

teaching certificate:

Certificate Title(s):

New York State License Number:

New York State License Number:

New York State Certificate Number (other than Social Security

Number, if any):

Permit Number:
Trainee's Signature:

mo.

Part B: Certification by Approved Provider

day

y r.

1. Provider must complete Part B.

2. Two copies should be returned to the trainee within ten calendar days of the completion of the coursework or training.
3. The provider of the coursework or training must retain a copy. This copy must be retained in the provider's files for not less than five years
from the date the course was completed
Pursuant to Chapter 544 of the Laws of 198, I certify that the person indicated in Part A has completed the required coursework or training
regarding the identification and reporting of child abuse and maltreatment.

Signature of Authorized Certifying Officer

GENIUS GENIUS OF NY, INC.

Approved Provider Name

Certificate #:

209132

EMILY MCNULTY

Name of Authorized Certifying Officer

10606

Identification Number

Certification of Completion Form, Rev 1.1 June 2006

07/26/2016

Date(s) of Coursework or Training

The University of the State of New York

THE STATE EDUCATION DEPARTMENT

Certification of Completion

(Coursework/Training in Identification and Reporting of Child Abuse and Maltreatment)

Part A: Trainee Information

This form is all that you need as proof that you have completed your mandated training. For all professions which
involve working in a school, your certificate will be sent electronically to the State and should appear on your
TEACH account within a week. For all licensing not related to the the Education professions, sign and date the
form, and then send it to the state along with your license application. This form is just one requirement for
certification/licensing. Other requirements include the application, transcripts, and, in some cases, passing exams.
For an application and further details on certification/licensing, call 1 (518) 474-3901 or visit the New York State
Education Department at www.nysed.gov
1

SOCIAL SECURITY NUMBER:

PRINT YOUR FULL NAME EXACTLY AS IT CURRENTLY APPEARS ON NEW YORK STATE EDUCATION DEPARTMENT RECORDS

(Leave this blank if you do not have a U.S. Social Security Number)

Last

First
Middle

Organization

Line 1

City/State
Country

BIRTH DATE:

02/10/90

Tkach

Alessia
M

Medaille College

M AILING ADDRESS
Line 2

(You must notify the Department promptly of any address or name changes.)

978 Upper Kenilworth

Hamilton Ontario
Canada

Zip code

Complete information below if you hold, or are applying for

professional license(s) or a permit:

Name of Profession(s):

L8W2L3
6

Complete information below if you hold, or are applying for a

teaching certificate:

Certificate Title(s):

New York State License Number:

New York State License Number:

New York State Certificate Number (other than Social Security

Number, if any):

Permit Number:
Trainee's Signature:

mo.

Part B: Certification by Approved Provider

day

y r.

1. Provider must complete Part B.

2. Two copies should be returned to the trainee within ten calendar days of the completion of the coursework or training.
3. The provider of the coursework or training must retain a copy. This copy must be retained in the provider's files for not less than five years
from the date the course was completed
Pursuant to Chapter 544 of the Laws of 198, I certify that the person indicated in Part A has completed the required coursework or training
regarding the identification and reporting of child abuse and maltreatment.

Signature of Authorized Certifying Officer

GENIUS GENIUS OF NY, INC.

Approved Provider Name

Certificate #:

209132

EMILY MCNULTY

Name of Authorized Certifying Officer

10606

Identification Number

Certification of Completion Form, Rev 1.1 June 2006

07/26/2016

Date(s) of Coursework or Training