Application for Approval

APPLICATION FOR APPROVAL

NASWSOCIAL WORK

CONTINUING EDUCATION HOURS

(Complete separate application for each program)

For office use only

Application Fee:______Receipt Number:______SWCEH Approved: ______

Date Fee Paid:______Approval Date:______Director: ______

APPLICANT AGENCY:______

ADDRESS:______

______

CITY/STATE/ZIP:______

PROGRAM TITLE:______

PRESENTER:______

DATE & TIME:______

SITE/CITY:______

Type of program:Seminar/WorkshopAudio/Video Presentation

(circle one) University ProgramProfessional Meeting/Presentation

Other:______

Requested number of Continuing Education Hours:______

(Continuing Education Hours include only direct hours of training. Do not count breaks, networking, meals, or social activities) A copy of each program agenda must be enclosed.

Presenter’s Professional Credentials/Qualifications:______

Please attach the following (documents containing several of these items together are acceptable):

____ The presenter(s) biography listing their professional expertise on training topic

____ A detailed agenda including breaks to help calculate CEHs approved

____ The evaluation form to be completed at the training by participants, with objectives

____ The flyer, brochure or registration form describing the training

Training Objectives (if on submitted brochure, objectives must be specific, measurable, and attainable):

1.______

2.______

3.______

4.______

Registration Fee Charged for the Training:$______(members)$______(non-members)

Anticipated enrollment:______

How will this program be evaluated?______

______

Will evaluation results be made available to the presenter(s)? ______Yes______No

AGENCY ADMINISTRATION

Program Planner:______

Phone #:______Email Address: ______

Who will maintain the records of program participants and certify their accuracy?

______

Will participants be provided with a certificate of attendance that includes the program title, date, sponsoring organization, and number of continuing education hours? ______Yes ______No

Is there liability insurance in place to cover this program/presentation? ______Yes______No

Is the facility hosting this trainingcomplaint with ADA standards? ______Yes______No

This organization has reviewed the National Association of Social Workers Center for Professional Development Standards for Continuing Education and Professional Development Programs and affirms that the proposed workshop is in full compliance with those standards.

______

Authorized Signature Date

______

Organization

APPLICATION FEE MUST ACCOMPANY THIS FORM.

Program Fees

1 to 8 hours $50

9 to 16 hours$85

17 to 24 hours$150

25 hours or more$225

This form should be submitted thirty days prior to workshop, or earlier if possible.

A letter of approval or denial will be returned to the applicant within 30 working days.

Please mail completed applications and payment to:

NASW Indiana - Center for Professional Development

1100 W. 42nd Street, Suite 226

Indianapolis, IN 46208

Fax: 317-925-9364

For Questions Contact: 317-923-9878 or – Thank You

C:\Users\josephine\Desktop\CEH Application.doc08/15/12