eHearsay DEI 2022 Edition Self Study Test Participant Information Question Title * 1. Completion Date (Your CE assessment will be graded and your participation documented in the next group submission when this group activity ends, on or shortly after June, 2022) MM/DD/YYYY Date Question Title * 2. Name (First and Last) Question Title * 3. Address Question Title * 4. Address Line 2 Question Title * 5. City, State and Zip Question Title * 6. Daytime Phone Number Question Title * 7. Alternate Phone Number Question Title * 8. Email: Question Title * 9. OSLHA Membership Number Question Title * 10. To Confirm Your Participation in This Activity, Do you Prefer a Certificate of Participation Emailed to You or Submission of Your Attendance to the ASHA Registry? (Your CE assessment will be graded and your participation documented in the next group submission when this group activity ends, on or shortly after June, 2022) CE Certificate Sent by Email Submission to the ASHA Registry Question Title * 11. ASHA requires that you be an ASHA Member or CCC holder or you be licensed or credentialed to practice speech-language pathology (SLP) or audiology or be preparing to practice in order to be eligible to earn ASHA CEU's. How are you qualified for ASHA CEU's? I am an ASHA Member I am a CCC Holder Licensed Certified Clinical Fellow Enrolled in a Graduate Program for SLP or Audiology Include your ASHA Number, CFY Supervisor name or Grad Program Name Next