Individual CE Approval Form (B)

ADAD Continuing Education Approval Form: Individual Submissions

State of Hawaii, Department of Health, Alcohol and Drug Abuse Division (ADAD)
Please read prior to completing this form:
- This form is intended for individuals who intend to participate in a scheduled continuing education activity and would like the activity approved for ADAD continuing education contact hour(s).
- This is a preapproval form. The application must be submitted and approved prior to the scheduled event.
- This form should only be completed if the activity is not already approved for ADAD continuing education contact hour(s).
Contact Information
Email*
example@example.com
Name*

First NameLast Name
Title
Phone Number
Please enter a valid phone number.
Additional Contact Email
example@example.com
For which of the following certifications are you planning on using the Continuing Education Activity for?*

Certified Substance Abuse CounselorCertified Prevention SpecialistCertified Clinical SupervisorCertified Criminal Justice ProfessionalCertified Program Administrator
Host of the Continuing Education Activity*
Is the Continuing Education Activity an in-service or training provided by your employer?*

YesNo
Title of Continuing Education Activity*
Continuing Education Activity Details - Dates, Times, & Location*
Date(s):

Time(s):

Location(s):

Other details:
Which of the following best describes the Continuing Education Activity?*

Virtual Synchronous Learning: Trainers and participants in different physical locations meet virtually at the same time to complete a training usually on programs such as Zoom, Teams, and Webex.In-Person Learning: Trainers and trainees are in the same physical location at the same time.Asynchronous Learning: Trainers provide pre-recorded trainings and/or other enduringmaterials; participants are able to choose the time, location and pace for learningindependently.Hybrid Learning: Integration of two or more of the above learning formats.
Which required certification training topic area is the CE Activity intended to address?*

Prevention EthicsCSAC, CCJP, CCS, CSAPA EthicsSubstance Use Disorder Confidentiality: 42 CFR Part 2HIV & STIsCultural AwarenessNone of the above
How will this Continuing Education Activity benefit you professionally?*
Please provide a copies of any brochures, flyers, announcements of the activity.*

Cancelof
Please upload a copy of the agenda for the event with start and end times for each presentation as well as the speaker listed. *

Cancelof
How many continuing education contact hours are being requested?*

Please indicate which sessions you plan to attend.*

	Duration	Title	Speaker
Presentation 1
Presentation 2
Presentation 3
Presentation 4
Presentation 5
Presentation 6
Presentation 7
Presentation 8
Presentation 9
Presentation 10

In agreement with the Policies and Procedures of the ADAD continuing education contact hours approval process, the individual submitting this application attests that the information provided about the continuing education activity is factual.

In submitting this application, I agree to hold the State of Hawaii Department of Health Alocohol and Drug Abuse Division, harmless for any claim, demand, or damage asserted by any third party due to or arising out of your use of or conduct on the service.

I understand that State of Hawaii Department of Health Alocohol and Drug Abuse Division is not responsible for CE advertisement, communicating with attendees, providing CE letters or certificates of attendances, etc.

I understand that the information contained within this application is not confidential. State of Hawaii Department of Health Alocohol and Drug Abuse Division reserves the right to list all approved CE on it's website and/or disclose approved CE titles to the public.

I understand that approval is not granted until payment is received and the authorization number will be provided at that time.
By checking the box below, you acknowledge and agree to the above.*

I agree.
Signature*

Clear
Please type your name.*
Please re-enter your email address.*
example@example.com
Should be Empty:

ADAD Continuing Education Approval Form: Individual Submissions

Please read prior to completing this form:

Contact Information