Professional Continuing Education Unit (CEU) Credits Request Form

Please provide the information below to consider your request for awarding CEUs.

Question Title

* 1. Request initiation date

Date / Time

Date

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* 2. Requestor Contact Information

Name *

Title

Agency, Division or Department Name

Address 1

City/Town

State/Province

ZIP/Postal Code

Supervisor Name

Email Address *

Phone Number *

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* 3. Trainer(s) name(s)

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* 4. Trainer(s) Qualifications (title, education, experiences)

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* 5. Course Title

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* 6. Course Description

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* 7. Training Location

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* 8. Training Date(s)

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* 9. Training Start and End Times

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* 10. Course Length (3 hours, 1-day, etc.)

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* 11. List the Benefits for Staff Taking the Course

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* 12. List Course Learning Objectives

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* 13. Attach Curriculum Assets (ppt, handout, etc.)

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

Choose File

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* 14. Maximum Number of Attendees Expected

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* 15. Attach your course evaluation

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

Choose File

Professional Continuing Education Unit (CEU) Credits Request Form

Question Title

* 1. Request initiation date

Question Title

* 2. Requestor Contact Information

Question Title

* 3. Trainer(s) name(s)

Question Title

* 4. Trainer(s) Qualifications (title, education, experiences)

Question Title

* 5. Course Title

Question Title

* 6. Course Description

Question Title

* 7. Training Location

Question Title

* 8. Training Date(s)

Question Title

* 9. Training Start and End Times

Question Title

* 10. Course Length (3 hours, 1-day, etc.)

Question Title

* 11. List the Benefits for Staff Taking the Course

Question Title

* 12. List Course Learning Objectives

Question Title

* 13. Attach Curriculum Assets (ppt, handout, etc.)

Question Title

* 14. Maximum Number of Attendees Expected

Question Title

* 15. Attach your course evaluation

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* 16. Plan for Tracking Attendance to Award CEUs

Question Title

* 17. Number of CEUs Requested