An NMSU Cooperative Extension Program

Family Peer Exposure Hours

Family Peer Support

Verification Form

This form should be filled out by the supervisor or other qualified individual who oversaw the exposure hours for a family peer support worker candidate.

  • This is the name of the supervisor or other qualified individual who oversaw the hours of a family peer support worker candidate.
  • Supervisor’s email
  • Supervisor’s phone
  • Supervisor’s title
  • Please provide the name of the program where the hours were completed
  • Candidates should complete 40 hours total. Hours may be completed at the same site or multiple sites. Please enter the number of hours completed in your program.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Please provide a general description of the activities completed and type of experiences the candidate participated in.

  • Applicant Exposed to Following Activities in this Agency:

  • During the work exposure the applicant exhibited the following skills or professional traits:

  • Do you have any concerns with this candidate completing certification as a Family Peer Support Worker and beginning working direction with parents and other caregivers. Do you recommend this candidate?

Return to Family Peer Support Home Page