Education Equivalency Application

Continuing Education (CEU) Activity Approval Application

Individuals Desiring to Request IACET CEU Approval Must Complete this Application and Receive Approval from the CPEI Education Committee at least 8 Weeks Prior to Event. In the event that a shorter time is requested please include that in the application.
Date Of Application*

MonthDayYear
Date
Date of Planned Activity*
Date if Requested Prior to 8 Weeks Approval Time*

MonthDayYear
Date
Name and Title Planner*

NameTitle
Email*
Name and Title of Presenter*

NameTitle
Name of Second Presenter

NameTitle
Continuing Education Program Title*
Learning Outcomes
Learning Outcomes (LOs). Describe what you expect your audience to be able to do after the presentation. It is not necessary to have a LO for each blank below - less enter NA. For example, the audience will be able to: #1: Describe the challenges faced by healthcare chaplains. #2: Analyze the reasons chaplains experience burnout.*
Calculate the number of IACET CEUs Total Hours to be awarded:

Using the following formula in hours: Contact time (Hrs) / 10 Hours = # CE

1 CEU = 10 Hours).

Example:

· 1 contact hour (60 Minutes) = 0.1 IACET CEUs

· 2 contact hours (120 Minutes) = 0.2 IACET CEUs

· 10 contact hours = 1.0 IACET CEUs
Identify the Scholarly Sources (Title, Author, Publisher). If less than 5 sources enter NA)*
Requested Number of CEUs? Remember that IACET defines CEUs as follows: 0.1 = 1 contact hour, 0.2 - 2 contact hours. Therefore, when you make payment enter the correct number of hours being requested.*
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Number of CEUs Requested. NOTE: 0.1 =1 contact hour. 0.2 = 2 contact hours. Jotform does not allow for the decimal; therefore, when it shows 1 that is equal to 0.1.Total number of Continuing Education (CEUs)
$15.00 Quantity

Invoice RequestSelect this option to be invoiced for the total number of CEUs requested. NOTE: 0.1 =1 contact hour. 0.2 = 2 contact hours. Jotform does not allow for the decimal; therefore, when it shows 1 that is equal to 0.1.
$ Free Quantity

Total

$0.00
Attach File Here (As Needed)

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1 Individuals or organizations sponsoring approved CE courses are responsible for ensuring that participants are aware of the requirements to earn credit.

2. Individuals or organizations sponsoring approved CE courses are responsible for informing participants of CEUs being offered.

3. Participants are required to submit for review a copy of their registration with a driver’s license or a government-issued photo for verification purposes.

4.Records are maintained by the sponsoring individual/organization to ensure the participants have met the required time for CE credit.

5. Training event providers will disclose in program materials conflicts of interest and dual relationships.
Phone Number*
Should be Empty:

Continuing Education (CEU) Activity Approval Application

Learning Outcomes