7/31/2019 Sample CE Course Offering Form

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Instructions: Respond to each of the questions below and attach required

information. Course and Offering Registration Form and required attachments must

be received before the:

15-day deadline if group or blended, or

30-day deadline if cooperative offering, individual learning experience (i.e., self-study) and/or any course requiring a pilot study.

Detailedinstructionsandadditionalformsneededforregisteringindividuallearningexperiences(i.e.,self-studycourses)and/orcoursesrequiringpilotstudyareavailableathttp://asha.org/ce/for-providers/admin/Forms.htm .

I. Course Information and Description

ProviderCode:

NameofASHAApprovedCEProvider:

CourseNumber:

CourseTitle:

CourseDescription:

SubjectCode: ContentCode: InstructionalLevel:

Willyouofferthiscoursemorethanonce?YesNo

TypeofLearningExperience(checkone):

Group(i.e.,live)Individual(i.e.,self-study)Blended

IfIndividualLearningExperience(i.e.,self-study),check oneandproviderequestedinformation:

First-timeregistering--withpeerreviewers(completeandattachtheProductInformationFormandPeerReviewForms.)

Course and Offering Registration FormAmerican Speech-Language-Hearing Association

Continuing Education Registry

AAAE

Massachusetts Speech Language Hearing Assn.

0648

Reading with TLC - Condensed Training

Course provided training in the use of Lively Letters, a multi-sensory mnemonic lettercard program. Participants learned language-based, structure techniques for trainingletter sound associations, phonemic awareness, phonetic decoding and acquisition of

sight words.

3010 P 2

http://asha.org/ce/for-providers/admin/Forms.htmhttp://asha.org/ce/for-providers/admin/Forms.htm

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First-timeregistering--editorialreviewboardconductedpeerreview(submitalistofreviewersandthedatethecontentwasacceptedbytheboard.)

Recordedversionofalivecourse(livetoself):Providelivecoursesnumber:

Re-registrationofcourse:Providepreviouscoursesnumber:

ListcourseofferingsonCourseSearch?YesNo

(Optional)Registrationcontact(nameandphonenumberorwebaddress,etc.):

II. Course CEUs

CEU amount:______.______(e.g.60minutes=0.1CEU,90minutes=0.15CEU,etc.)

How did you determine the CEU amount?(checkallthatapplyandproviderequestedinformation)

Time-orderedagenda/seattime(attachagenda)

Runtimeofrecording(attachagenda)

Pilotstudy(completeandattachPilotStudyForm)

Establishedwordcount,insertformula:

Previouslyestablished.Providethecoursenumberwhereestablished:

Can participants earn partial credit for this course?

No(continuetopromotionalmaterialssection)

Yes(respondtothefollowing)

Howwillcourseparticipantswhodonotattendtheentirecoursedemonstrateachievementofthecourselearningoutcomes?(checkone):

Thecoursehasmultiplesessionsandeachsessionhasdiscretelearningoutcomesthatareassessedattheendofeachsession.

Thecourseisaseries.Participantsmustattendaminimumofsessionswithintheseries.

Apassingscoreonanexamisthesatisfactorycompletionrequirement.

Participantswillsuccessfullydemonstrateaskillasthesatisfactorycompletionrequirement.

Thecoursehasgroupandindividuallearningcomponents.Participantscanoptoutoftheindividuallearningportionofthecourseandearncreditforthegrouplearningonly.

Other(pleasedescribe):

Nancy Telian 781-812-0393

0 0 6 0

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III. Promotional Materials

Promotionalmaterials(AttachcourseadvertisementwhichmustincludetheASHACEApprovedProviderBrandBlockandCEUsentence.)

IV. Course Design

Needs Assessment Process(checkallthatapply):

Interviewedkeyindividuals Conductedfocusgroup(s)

Surveyedsamplepopulation Other(pleasedescribe):

Learning Outcomes:

Attachcourseslearningoutcomes

Assessment of Learning Process(checkallthatapply):

Performancedemonstrations Completionofaproject

Writtenreport Writtenexamination

Oralreport Oralexamination

Self-assessment Questionandanswersession

Other(pleasedescribe):

Instructional Methodology(checkallthatapply):

Lecture Smallgroupactivity

Videooraudiopresentation Paneldiscussion

Demonstrationofprocedures Observationofpatients

Casestudy Simulations

Other(pleasedescribe):

V. Planning and Instructional Personnel

Yes,wehaveaprocessforidentifyingandselectinginstructionalpersonnelthatmeetsASHACEBRequirement6.

IfyouprovidedinformationabouttheprinciplesofEvidence-BasedContinuingEducationtoplannersand/orinstructorsduringcoursedevelopment;pleaseindicatetheresourcesprovided(checkallthatapply):

Directedtheplannerand/orpresenterofthecoursetoASHACEsEvidence-BasedCETutorial onASHAswebsite.

http://www.asha.org/ce/for-providers/EBCETutorialIntro.htmhttp://www.asha.org/ce/for-providers/EBCETutorialIntro.htm

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Gavetheplannersand/orpresentersofthecoursetheGuidanceonInfusingEvidenceintoCECourseContent[PDF]foundonASHAswebsite.

Other(describe)

Howwillyoudisclosetoparticipantstheproprietaryinterest(s)and/orafiliationofeachinstructororcourseauthor?(checkallthatapply):

Announcementbyinstructor/speaker

Printedinformationdistributedtoparticipants

Announcementbyindividualintroducingtheinstructor/speaker

VI. Satisfactory Completion and Course Evaluation

HowwillyoudeterminewhetherparticipantsmeetthecoursessatisfactorycompletionrequirementsandareeligibletoearnASHACEUs?(checkallthatapply):

Attendance Attainmentoflearningoutcomes

Course valuation:

Yes,wehaveaprocessforevaluatingthiscourseandusingtheevaluationresultstomakeimprovementsthatmeetsASHACEBRequirement11.

VII. Course Offerings

Iftherearemorethantwelveplannedofferings,please attach the Additional OfferingsList.

StartDate EndDate City,State,Country(ifapplicable)

Isthisacooperativeoffering?Seefeeschedule

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

01/14/2011 01/14/2011 New Rochelle, NY

http://www.asha.org/CE/for-providers/Continuing-Education-Fees/http://www.asha.org/CE/for-providers/Continuing-Education-Fees/

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Cooperative Offering Information:

Forthoseofferingscheckedascooperative,providetherequestedinformation.(Iftherearemultiplecooperativeorganizations,attachalistofdatesandcooperativeorganization,contactname,phoneandemail.)

Namesofcooperativeorganization:

Contactnameatcooperativeorganization:

Phonenumberforcontact:

E-mailaddressforcontact:

IstheotherorganizationanASHAApprovedCEProvider?YesNo

Ifno,pleaseprovidepayment.The non-refundablecooperativeofferingfee(s)mustbesubmittedwiththisform.

Totalamount(creditcardorcheck)$

Check.Checknumber:

Creditcard(MasterCardorVisa,)completethefollowing:Creditcardnumber:

Expirationdate:

Nameasitappearsoncard:

VIII. Attestations and Signature

Pleasereadandcheckeachboxindicatingthatyouagreeto:

retaininformationabouttheplanning,implementation,andevaluationandrecordsof

attendanceforthiscourseandallitssubsequentofferingsfor2yearsaftertheenddateofthecourseoffering.

reviewtheCourseRegistrationConfirmationandnotifytheCERegistryofanycorrectionswithin15daysofreceipt.

checktheCECourseRosterandnotifytheCERegistryofanycorrectionswithin45days.

retaintheparticipantsnamesandASHACEUsearnedforaminimumof2yearsfromthecompletiondateofthecourseoffering.

submitCourseandOfferingRegistrationForms,requiredattachmentsandcooperative

offeringfees(ifapplicable)bythe15-dayor30-daydeadline.

Reading with TLC

Nancy Telian

781-555-1212

250.00

xxxx-xxxx-xxxx-xxxx

04/11

Name Card

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RespondonlyifyourorganizationhasaCEConsultant:

ensurethathe/sheparticipatedintheplanningofthecourseandhasreviewedtheCourseandOfferingRegistrationinformation.

IunderstandthatanappeallettermustbesubmittedtotheCEBifacompleteand

compliantCourseandOfferingRegistrationForm,requiredattachmentsandcooperativeofferingfees(ifapplicable)arereceivedbytheCEBafterthe15-dayor30-daydeadline.

ASHACEAdministratorsName Originalsignature

Date:

EithermailorfaxthecompletedCourseandOfferingRegistrationForm,therequiredattachments,andthecooperativeofferingfees(ifapplicable)to:

Mailing address for registrations without fees:ContinuingEducation,ASHA,2200ResearchBlvd.#340,Rockville,MD20850

Mailing address for registrations including cooperative payment(s): ContinuingEducation,ASHA,P.O.Box1160#340,Rockville,MD20849

Faxnumber:301-296-8574

8324

Maureen Markt Dearborn

11/22/2010