In order for this course to be valid to fulfill the didactic education requirement for certification, your name must be on the official list submitted to BCIA by the training program you attended. Additionally, you must complete this evaluation form within 30 days of the completion of the training program. The information submitted will be kept confidential by BCIA; however summary results may be tabulated and shared with the BCIA Accreditation Committee or the specific training program. The summary data received by the training program will be used to provide feedback for the improvement of their teaching program.

* 1. Your Name:

* 2. Your email address:

* 3. Name of BCIA Accredited Training provider:

* 4. Location of training program (city, state):

* 5. Date of training program (month, year):

* 6. Year: