APPLICATION FOR USE OF INFORMATION FROM THE CRCC
DATABASE AND/OR SPONSORSHIP OF A RESEARCH PROJECT

The Commission on Rehabilitation Counselor Certification (CRCC) recognizes the value of scientific research and development to its certified professionals and the public; and that from time to time CRCC will be requested by outside entities to provide information from the database for further research. Furthermore, that outside entities may request sponsorship from CRCC in terms of the contribution of hard and soft funds. Sponsorship may be granted only when the research is directly related to rehabilitation counseling.

The Examination and Research Committee must review any study using information from the CRCC database for approval.

Please be advised that CRCC does not allow the awarding of continuing education for research projects that are not sponsored in whole or in part by CRCC.

This application is designed to secure the pertinent details of a request for information from CRCC’s database or for sponsorship in a manner that provides anonymity of the requesting individual(s) so as to ensure that a blind review of the information is conducted by the Examination and Research Committee. Therefore, we request that the individual(s) submitting the application provide their name or other identifying information only in the areas requested and that this application be returned directly to CRCC to the attention of the Executive Director at 300 N. Martingale Road, Suite 460, Schaumburg, IL 60173. Questions can be directed to (847) 944-1325 or info@crccertification.com.

Please Complete All Information for the Principal Researcher for this Project.
 
Principal Researcher’s Name   Daytime Telephone Number
 
Company Name   Facsimile Number
 
Address   E-mail Address
 
 
City / State / Province   Country   Zip / Postal Code

Please List the Names of Additional Researchers

CRCC requires the submission of quarterly reports as to the progress of the project.

Do the researchers agree to comply with these policy requirements? YES NO

Where any information from CRCC’s database is requested for use in a research project or dissertation thesis, policies of CRCC require that data be made available only to those who intend to submit research findings for publication, preferably to a peer reviewed publication. CRCC requires acknowledgement of its contributions in all publications. (RECOMMENDED CITATION: This Research Project has been supported with resources from the Commission onRehabilitation Counselor Certification. (CRCC).

Do the researchers agree to comply with these policy requirements? YES NO

Where any information from CRCC’s database is requested for use in a research project or dissertation thesis, policies of CRCC require that the data can only be used within one year from obtainment to the point of submission of findings for publication. If submission of findings for publication is not made within one year from the point of obtainment of data from CRCC, the researchers would be required to submit a request to CRCC for continued use of the data.

Do the researchers agree to comply with these policy requirements? YES NO

Where any information from CRCC’s database or funding of any sort is received from CRCC for use in the research project, policies of CRCC require that all published research be provided to CRCC free of charge.

Do the researchers agree to comply with these policy requirements? YES NO

Where any information from CRCC’s database or funding of any sort is received from CRCC for use in the research project, policies of CRCC require that the researchers submit an Executive Summary to CRCC that includes contact information for the researchers and that CRCC be given exclusive permission to make the Executive Summary available to the public in electronic or other media. The Executive Summary should be a one-page typewritten, single-spaced document.

Do the researchers agree to comply with these policy requirements? YES NO


Please attach the following documents for review by the CRCC Examination and Research Committee:

1)

A written research proposal outlining: a) the scope and purpose of the research project, b) specific information requested from CRCC’s database and/or a detailed accounting of hard or soft funding requested, and c) the intended use of the information from CRCC’s database or of funding requested in relation to the scope and purpose of the research project, d) provide a detailed project timeline indicating start and completion dates for each phase of the research project. Please do not list identifying information within the research proposal.

2)

A copy of the written approval from an institution’s human subjects review board (IRB) or, if not previously required, documentation to ensure the protection of human subjects.

3)

A copy of the instrument to be used to obtain the information required for completion of the research project.

If the nature of this request pertains in whole or in part to the attainment of names and addresses from CRCC’s database of certified professionals, please complete the attached Mailing Rental Request Form.

Statement of Understanding: I the undersigned, as principle researcher, attest that to the best of my knowledge, the responses and information provided as part of this application are true.


Principal Researcher’s Signature Date

Published: 12/00
Rev 04/07
db application.doc
RECOMMENDED CITATION

Commission on Rehabilitation Counselor Certification. (2007).
Application for Use of Information from the CRCC Database and/or Sponsorship of a Research Project.
Retrieved [date] from, http://www.crccertification.com/pages/31research.html


MAILING RENTAL REQUEST FORM

CRCC will rent the names and addresses of Certified Rehabilitation Counselors (CRCs) who have agreed to have their contact information available for research projects. These data are for one-time use only in accordance with the project outlined in the submission to CRCC’s Examination and Research Committee. The minimum charge for up to 1,000 names/addresses is $250.00 (USD). An additional charge of $50.00 (USD) applies for additional names/addresses in increments of 250. Please complete the following:

Indicate the certification mailing list from which you wish to rent data:
(Approximate # of Names/Addresses Available)
Certified Rehabilitation Counselor (CRC)
 Canadian Certified Rehabilitation Counselor (CCRC)
10,500
00,250

Indicate the state(s) or province(s) that you wish to receive
OR indicate ALL states or ALL provinces OR Random Sample and enter the number:
State
AK AL AR AZ CA CO CT DC DE
FL GA HI IA ID IL IN KS KY
LA MA MD ME MI MN MO MS MT
NC ND NE NH NJ NM NV NY OH
OK OR PA RI SC SD TN TX UT
VA VT WA WI WV WI All
Random
Sample
Province
AB VBC MB NB NL NS NT NU ON
PE QC SK YT All
Random
Sample
Other
Foreign Countries Territories

Select Format:
Pressure Sensitive Labels (Sticky Peel Off Labels)
 Electronic File (CVS)

You are entitled to a paper listing of the same information so that you may, for example, verify receipt of survey instruments. Do you wish to receive the paper listing? YES NO
Indicate the Sorting Order:
Zip Code Order
 Alphabetical Order by Last Name

Indicate the bill to and ship to addresses:

BILL TO:
SHIP TO:
Name Name
Company Name Company Name
Address Address
City, State / Province, Zip / Postal Code, Country
City, State / Province, Zip / Postal Code, Country

If the CRCC Examination and Research Committee grants approval for this request, you will be sent a contract and invoice for the charges. Please allow a minimum of four weeks following receipt of payment and the contract for delivery of the mailing labels.

“I, the undersigned, acknowledge that the mailing labels are for one-time use and will be used only within the parameters designated in the research proposal. I agree that I will not reproduce or sell these mailing labels.”

Signature Date
Printed Name Telephone Number (including area code)

Published: 12/00
Revised: 04/07
Mailing label request form

RECOMMENDED CITATION
Commission on Rehabilitation Counselor Certification. (2007). Mailing Label Request Form.
Retrieved [date] from, http://www.crccertification.com/pages/31research.html