ADAD CE Approval Form (A)

ADAD Continuing Education Approval Form: Training Organizer Submissions

State of Hawaii, Department of Health, Alcohol and Drug Abuse Division (ADAD)
Please read prior to completing this form:
- This is a preapproval form. The application must be submitted and approved prior to the scheduled event.
- This form is intended for organizations that are intending to host an educational activity and would like preapproval that the activity meets the requirements to be approved continuing education contact hour(s).
Contact Information
Email*
example@example.com
Name*

First NameLast Name
Title
Phone Number
Please enter a valid phone number.
Organization/Program*
Additional Contact Name

First NameLast Name
Additional Contact Email
example@example.com
Title of Continuing Education Activity*
CE Activity Details - Dates, Times, & Location*
Date(s):

Time(s):

Location(s):

Other details:
Which of the following best describes the CE 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.
How does this training relate to the behavioral health or substance use fields?*
Who is the intended audience of the continuing education activity?*

Prevention ProfessionalsTreatment ProfessionalsBehavioral Health ProfessionalsMedical ProfessionalsCriminal Justice ProfessionalsOpen to the publicOther
If selected "Other" please describe the audience:*
CSAC Core Functions and CPS Performance Domains and Job Tasks

The following questions refer to the 12 Core Functions of the Alcohol and Other Drug Abuse Counselor and the Prevention Performance Domains and Job Tasks found within the CSAC and CPS applications respectively. Please find the links below for your reference.
- 12 Core Functions of the Alcohol and Other Drug Abuse Counselor (p. 14 in the CSAC Application)
- Prevention Performance Domains and Job Tasks (p. 11 in the CPS Application)
What 12 Core Function areas are the CE Activity intending to address?*

ScreeningIntakeOrientationAssessmentTreatment PlanningCounselingCase ManagementCrisis InterventionClient EducationReferralReport and Record KeepingConsultation with other professionals in regard to client treatment and servicesNone of the above
What Prevention Domains are the CE Activity intending to address?*

Planning and EvaluationPrevention Education and Service DeliveryCommunity OrganizationCommunicationPublic Policy and Environmental ChangeProfessional Growth and ResponsibilityNone of the above
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
Learning Objectives: Learning objectives provide direction in the planning of a training CE. They help to (1) focus on the learner’s behavior that is to be adjusted; (2) serve as guidelines for content, instruction, and evaluation; (3) identify specifically what should be learned; and (4) convey to learners exactly what is to be accomplished.

In reviewing your application, we will be looking for learning objectives which include: identification of a specified action by the CE attendee that is: observable; measurable; and demonstrated by the CE attendee.

Each learning objectives must be measurable.
What are the learning objectives for the CE activity?*
Is this course open to the public?*

YesNo
If you indicated that the course is open to the public, this approval information will be sent to our training partners to advertise in an effort to broaden workforce access to available trainings. If you DO NOT want the training information shared, please select "Opt-out" below.

Opt-out
What is the capacity limit of this training?*
How many continuing education contact hours are being requested?*
Supporting Documents
Please upload a copy of the agenda for the event with start and end times for each presentation. *

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Speaker Bios*

Cancelof
Draft Credit Letter or Attendance Verification Template*

Cancelof
Evaluation*

Cancelof
Draft Slide Deck*

Please upload a drafted slide deck of this presentation for review.
Cancelof
In agreement with the Policies and Procedures of the State of Hawaiʻi Department of Health, Alcohol and Drug Abuse Division (ADAD) continuing education (CE) contact hours approval process, the provider of the continuing education activity will:
- Provide each participant a certificate of completion by the entity delivering the CE. The certificate must include: the name of the participant, session date(s), session title(s), the number of continuing education contact hours earned by the participant, the ADAD individual session authorization number, and printed name and signature of the provider.
- Attach a sample evaluation tool to this application. Providers are required to keep evaluation material as described in Hawaii State Law/Statute/Administrative Rules.
- After each training, trainer must retain attendance list which includes printed names and signatures of each attendee, agenda, copy of sample session certificate to include the name of the CE training entity, CE session date(s), the name/titles of the session trainer, the CE session title and date(s), the number of CE hours earned by the participants and a signature of the approved trainer, as well as other requirements as specified in Hawaii State Law/Statute/Administrative Rules.
- Provide the attendance list and a summary of the training evaluation results upon request by ADAD or ADAD designee.
In submitting this application, I agree to comply with the reasonable accommodations provisions of the American with Disabilities Act. (Information regarding the American Disabilities Act can be found at http://www.ada.gov/.)

In submitting this application, I agree to hold the ADAD 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 the ADAD is not responsible for CE advertisement, communicating with attendees, providing CE letters or certificates of attendance, etc.

I understand that the information contained within this application is not confidential. ADAD reserves the right to list all approved CE on its 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
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ADAD Continuing Education Approval Form: Training Organizer Submissions

Please read prior to completing this form:

Contact Information

CSAC Core Functions and CPS Performance Domains and Job Tasks

Supporting Documents