Kentucky Department for Public Health Community Health Workers CEU Application

Please read the following information regarding CEU submittion.

Thank you for your interest in providing continuing education units for Certified Community Health Workers in Kentucky. Please review this form and requirements carefully before submitting your application.

This form must be completed for each unique trainings you wish to provide CEUs. If you have a reacurring training that the information stays the same you do not need to do multiple CEU submittions. Just note in the date sections ALL dates the training will be held.

Applications should be submitted at least four weeks prior to the training date.

Contact Hours

Trainings must provide at least 50 minutes of continuous participation to receive one contact hour. Applicants may request a half (0.5) contact hour if they provide 30 minutes of continuous participation.

Certificates

Certificates are required for CCHW CEUs.

All applicants must provide and retain copies of a certificate of completion for each CCHW who successfully completes the training. Certificates should be kept for a minimum of three (3) years. Certificate templates are available upon request.

Certificates must include:
- Name of Training Organization
- Title of Training
- Date of Training
- Name of CCHW
  - Official CEU Statement (below)
    "This training is approved by the Kentucky Department for Public Health Office of Community Health Workers to provide X continuing education units for Certified Community Health Workers."
    Evaluation
Evaluation

Evaluations are required for CCHW CEUs.

Applicants must provide the standard evaluation questions provided by the Kentucky Office of Community Health Workers (KOCHW).

Additional questions may be added as needed, but the standard questions cannot be changed. Trainers must retain copies of evaluations for each CCHW who successfully completes the training.

Evaluations should be kept for a minimum of three (3) years. The KOCHW may request evaluation results at any time.

Review and Approval

Once submitted, applications will be reviewed by the KOCHW staff. All applicants will be notified in writing regarding approval or disapproval at least five days prior to the scheduled training date listed on the application as long as the application was recieved within the 4 week prior timeframe.

For questions please email the KOCHW office at CHW.Certification@ky.gov.

Program Information
Organization Name:*
Training Coordinator Name:*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

Training Information

Check all that apply.
Name of Training*
Type of Training*

In person-MeetingIn person-ConferenceOnline Conference (Zoom, Go to Webinar, etc.)Online meeting (Zoom, Go To Webinar, etc.)Recorded Online Meeting housed on KY TRAIN LMSModule/Asynchronous training house on KY TRAIN LMSOther
If other, please explain training. *

Training Information
Facility Name:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Training Information
Expected Audience Size:*
Length of Training:*
Number of CEUs Requested:*
Cost of Training:*

Training Occurrence

If this is a reoccurring training, please indicate how often is will take place and on which dates.
Training Occurrence:*

One-timeQuarterlyMonthlyBi-AnnuallyOn-Demand

Date of training:*

YearMonthDay
Date
Time of the Training:*

List Dates*
Time of the Training:*

Registration Process:*
Target Audience:*
Training Description:*
SMARTIE Objectives:*
Would you like the KOCHW to advertise your training in the KOCHW Connection (bi-monthly newsletter).*

YesNo

Training Files

Training evaluation and a certificate of completion are required for ever CE training.
Training Agenda:

All Conferences and/or workshops need to provide the training agenda.
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Training Evaluation:

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Click here to see the required evaluation questions.
Certificate of Completion:

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Click here to see a sample Certificate with all required items.
Training Flyer:

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Instructor Information
How many instructors will be participating?*
If more than 50 instructors, notify the KOCHW.

Instructor One Information
Name*

First NameLast Name
Degree/Certification*
Position*
Email*
example@example.com
Instructor CV/Resume*

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Instructor Two Information
Name*

First NameLast Name
Degree/Certification*
Position*
Email*
example@example.com
Instructor CV/Resume*

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Instructor Three Information
Name*

First NameLast Name
Degree/Certification*
Position*
Email*
example@example.com
Instructor CV/Resume*

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Instructor Four Information
Name*

First NameLast Name
Degree/Certification*
Position*
Email*
example@example.com
Instructor CV/Resume*

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Instructor Five Information
Name*

First NameLast Name
Degree/Certification*
Position*
Email*
example@example.com
Instructor CV/Resume*

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Instructor Six Information
Name*

First NameLast Name
Degree/Certification*
Position*
Email*
example@example.com
Instructor CV/Resume*

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Instructor Seven Information
Name*

First NameLast Name
Degree/Certification
Position*
Email*
example@example.com
Instructor CV/Resume*

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Instructor Eight Information
Name*

First NameLast Name
Degree/Certification*
Position*
Email*
example@example.com
Instructor CV/Resume*

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Instructor Nine Information
Name*

First NameLast Name
Degree/Certification
Position*
Email*
example@example.com
Instructor CV/Resume*

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Instructor Ten Information
Name*

First NameLast Name
Degree/Certification*
Position*
Email*
example@example.com
Instructor CV/Resume*

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Instructor Eleven Information
Name*

First NameLast Name
Degree/Certification*
Position*
Email*
example@example.com
Instructor CV/Resume*

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Instructor Twelve Information
Name*

First NameLast Name
Degree/Certification*
Position*
Email*
example@example.com
Instructor CV/Resume*

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Instructor Thirteen Information
Name*

First NameLast Name
Degree/Certification*
Position*
Email*
example@example.com
Instructor CV/Resume*

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Instructor Fourteen Information
Name*

First NameLast Name
Degree/Certification*
Position*
Email*
example@example.com
Instructor CV/Resume*

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Instructor Fifteen Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Sixteen Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Seventeen Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Eighteen Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Nineteen Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Twenty Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Twenty-One Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Twenty-Two Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Twenty-Three Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Twenty-Four Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Twenty-Five Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Twenty-Six Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Twenty-Seven Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Twenty-Eight Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Twenty-Nine Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Thirty Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Thirty-One Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Thirty-Two Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Thirty-Three Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Thirty-Four Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Thirty-Five Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Thirty-Six Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Thirty-Seven Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Thirty-Eight Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Thirty-Nine Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Forty Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Forty-One Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Forty-Two Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Forty-Three Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Forty Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Forty-Four Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Forty-Five Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Forty-Six Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Forty-Seven Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Forty-Eight Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Forty-Nine Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Instructor Fifty Information
Name

First NameLast Name
Degree/Certification
Position
Email
example@example.com
Instructor CV/Resume

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Attestation
I attest that all of the information provided in this document is true and complete. I understand that providing false or misleading information may result in the denial or revocation of continuing education hours.
I attest that the technical and education competencies of the training instructor(s) are relative to the program objectives.
I understand that this application and all supporting documentation become the property of the Kentucky Department for Public Health and are not returnable.
I attest that I understand this activity must be free of commercial bias for or against any product and is evidence-based.
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Program Information

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Training Information

Training Information

Training Occurrence

CHW Core Competencies

Training Files

Instructor Information

Attestation