12 NCAC 09I .0110 Certification Forms – Juvenile Justice

The following are Commission-approved forms to be used by individuals certified as, or applicants for certification as, juvenile justice officers or juvenile court counselors:

(1) Form F-5A (JJ), Application for Certification - Juvenile Justice Officer & Juvenile Court Counselor, shall include the following:

(a) name, phone number, and address of employing agency;

(b) applicant's name, previous names used, social security number, home address, date of birth, driver's license number and issuing state, email address, and phone number;

(d) position title and full-time or part-time status;

(e) verification that the applicant has completed certification requirements as set out in 12 NCAC 09B .0116 or .0117, including:

(i) education information, including highest level of education, name and location of high school, type of higher education degree earned, name and location of higher education institution, and how each type of education and/or degree was verified by the employing agency;

(ii) drug screening date, result, and name of laboratory;

(iii) date submitted fingerprints to State Bureau of Investigation and results shall be attached;

(iv) psychological screening date and the name and license number of the evaluating psychologist or psychiatrist;

(v) indication that medical forms, pursuant to .0105 of this Subchapter, have been completed, date of medical examination, and name and license number of examining medical professional;

(vi) indication that background investigation and associated forms, pursuant to 12 NCAC 09B .0102, have been completed;

(vii) indication of whether the applicant has prior military experience and attached military records if applicable;

(viii) employment history of the applicant, supported by Form F-8, pursuant to 12 NCAC 09B .0102, if applicable;

(ix) attached a completed Form F-36, pursuant to 12 NCAC 09I .0116; and

(x) applicant's arrest, criminal, probation, and Domestic Violence Protective Order history, supported by Form F-3, pursuant to 12 NCAC 09B .0102, if applicable;

(f) date completed Application for Verification of Expungement AOC-CR-280;

(g) signature of applicant and date signed; and

(h) name, title, and signature of executive officer or authorized representative of the employing agency and date signed.

(2) Form F-5D (JJ), Application for Change in Juvenile Justice Certification, shall include the following:

(a) facility or district of employment;

(b) applicant name, academy ID number, social security number, date of birth, email address, home address, and phone number;

(d) type of certification transferring to;

(e) effective date of transfer;

(f) full-time or part-time status;

(g) education information, including how the applicant's high school education was verified by the employing agency, how the applicant's college education was verified; type of college degree earned; and institution name;

(h) notarized signature of the applicant; and

(i) name, title, and signature of executive officer or authorized representative of the employing agency and date signed.

(3) Form F-19 (JJ), Notification of Personnel Record Change, shall include the following:

(a) employing agency name;

(b) individual's name on file with the Division, academy ID number, date of birth, and social security number;

(i) new full name;

(ii) reason for name change; and

(iii) attached documentation, if applicable.

(d) for those notifying of a status change:

(i) current full-time or part-time status; and

(ii) status changing to;

(e) name, title, and signature of agency head and date signed.

History Note: Authority G.S. 17C‑6;

Eff. October 1, 2026.