MMI Activity Report for Continuing Education & Community Training

Definition of Continuing Education: Seminars, workshops, symposia, conferences or courses of instruction offered by MMI that: (1) serve to maintain professional credentials; (2) expand the knowledge base of professionals on new developments; and (3) offer CEUs (or equivalents) or certificates of completion to obtain CEUs. Definition of Community Training: Workshops, conferences, or training provided by MMI faculty or staff to enhance the knowledge or skills of community members (individuals with disabilities, families, paraprofessionals, policy-makers, students or others in the community). Training or educating individuals with developmental disabilities or their family members should be recorded using the “Other Direct-Model Services” form. Program type UCEDD LEND Date of Activity (or beginning date) / / Duration (nearest full hour) Recurring Activity? Yes No Was this training conducted outside of MMI? Yes No Title of Activity: Brief Description: Staff Involvement: (list all MMI staff involved in the activity) The primary target audience is Training method Venue Are CEUs offered? Yes No Are certificates of completion offered? Yes No Type of Activity Area of Emphasis from the DD Act (choose one):

Quality Assurance Education & Early Intervention Child Care Health Employment Housing Transportation Recreation Quality of Life Assistive Technology Cultural Diversity Leadership Other (Please Specify)

Types & Numbers of Participants: Students/Trainees/Interns/Post-Docs Children/Adolescents with Disabilities Professionals & Para-professionals Legislators/Policymakers Family Members/Caregivers General Public/Community Members Adults with Disabilities

Participant Satisfaction: “As a result of this training, my knowledge of (insert training topic) has increased” Was MMI the lead on this activity? Yes No

If yes, number surveyed for satisfaction (breakdown the number surveyed below)

Strongly Agree Agree Disagree Strongly Disagree

Names of Agencies Collaborating on the Work of the Activity (list all): Topic of Continuing Education (LEND Activities only):

Not Applicable/No Collaborating Agencies Topic of Continuing Education List A (select one) List B (select all that apply)

Women's /Reproductive/ Perinatal Health Mental/Behavioral Health Early Childhood Health/ Development (birth to school age) Nutrition School Age Children Oral Health Adolescent Patient Safety CSHCN/Developmental Disabilities Respiratory Disease Autism Vulnerable Populations Emergency Preparedness Racial and Ethnic Diversity or Disparities Health Information Technology Other (describe)

Affiliated MMI Projects/Programs: Primary Secondary

Not Applicable/No Affiliated Project or Program Did this training address ASD or a related disability? Yes No Geographic scope Name of person completing this form MMI Department You may also save this form on your computer by giving each record a unique name. This is recommended if you will be repeating this same activity in the future. Click the SUBMIT button to send this record directly to Paula Swanson.