PLEASE NOTE: IT WILL TAKE 30 days from the date of your application to issue your CEU credit.

Please complete this online form within 60 days of the live date of each web seminar to be eligible for CEU credit. You can attend the live event or take advantage of the recorded program to claim your free CEU credit (thanks to Home Instead Senior Care). Event recordings are available for 60 days after each live web seminar.

Your CEU certificate will be emailed to you at the address you provide.

Please note that there is a limit of one Board selection per person per event. Also note that IT WILL TAKE 30 days to issue your CEU credit. Thank you for viewing the web seminar and completing this form for CEU credit.

* 1. Please enter your contact information below.

* 2. Please enter your license number here. If you do not have a license number, please enter N/A

* 3. Profession / Occupation:

* 4. The email address that you used to access the live OR recorded webinar to verify attendance. You MUST enter the EXACT email address you used to attend the live OR recorded webinar; entering a different or incomplete email address will prevent your CEU from being issued. If you are unsure of the email you used to attend, check your original confirmation email. 

* 5. Choose ONE webinar date for "Home Safety: Aging in Place" which you are requesting CEUs. If you attended the live session, you MUST select the correct date to qualify. Check your follow-up email if you're not sure.

CEUs are only available for 60 days following the live event. Also note that IT WILL TAKE 30 days from the date of your application to process and issue your CEU credit. Your CEU’s will be emailed to you.

* 6. Session format:

* 7. Date(s) webinar was viewed (must be within 60 days of the live event to receive CEU credit):

* 8. Select the BOARD for which you are requesting Continuing Education Credit (limit ONE board per attendee, per event).

If your profession or state or national board is not listed on the Board Approval List, please verify with your board or association regarding acceptance of one of the providers listed below before applying for CEUs.

* 9. I acknowledge and understand that if I chose Certificate of Completion in Question 8 above that I will NOT be issued a CEU credit. I acknowledge and understand that if I chose Certificate of Completion in Question 8 above, I CANNOT request a CEU credit at a later date for this session. I acknowledge and understand that if I did NOT choose Certificate of Completion in Question 8 above, the preceding does not apply to me.

* 10. If you selected Association of Social Work Boards (ASWB) OR American Occupational Therapy Association (AOTA) as your Board in question 8 above, you MUST complete the following 10 post-test questions, as required by ASWB and AOTA. Anyone selecting ASWB or AOTA who fails to complete the following 10 questions WILL NOT earn a CEU.

If you DID NOT select Association of Social Work Boards or American Occupational Therapy Association as your Board in question 8 above, you may skip ahead to question 19.

Association of Social Work Boards (ASWB) and American Occupational Therapy Association (AOTA) question 1:

According to adult children in the US, _____% of senior’s homes have at least one potential safety issue.

* 11. Association of Social Work Boards (ASWB) and American Occupational Therapy Association (AOTA) question 2:

Some medications or combinations of medicines can have side effects such as dizziness or drowsiness making a fall more likely.

* 12. Association of Social Work Boards (ASWB) and American Occupational Therapy Association (AOTA) question 3:

By the time someone is 60years old, pupils decrease to about ____ the size they were at the age of 20.

* 13. Association of Social Work Boards (ASWB) and American Occupational Therapy Association (AOTA) question 4:

Participating in activities like walking, water workouts and tai chi, can help seniors prevent falls.

* 14. Association of Social Work Boards (ASWB) and American Occupational Therapy Association (AOTA) question 5:

______% of seniors in the US have done nothing to prepare their homes for aging.

* 15. Association of Social Work Boards (ASWB) and American Occupational Therapy Association (AOTA) question 6:

Clutter won’t cause accidents in a senior’s home, so don’t use your time to organize scattered magazines, trash and newspapers.

* 16. Association of Social Work Boards (ASWB) and American Occupational Therapy Association (AOTA) question 7:

Which of the following is NOT a solution to power cords in senior homes.

* 17. Association of Social Work Boards (ASWB) and American Occupational Therapy Association (AOTA) question 8:

Nearly _____% of accidents that happen in US senior homes can be prevented.

* 18. Association of Social Work Boards (ASWB) and American Occupational Therapy Association (AOTA) question 9:

What is the recommended solution to slick floor in the bathroom?

* 19. Association of Social Work Boards (ASWB) and American Occupational Therapy Association (AOTA) question 10:

Decreased blood flow to nerve endings as we age can reduce the sense of pain and temperature

* 20. I am motivated to apply what I learned in this webinar to my work.

* 21. Please provide three examples of how you will apply what you have learned in this webinar to your work:

* 22. The session content fulfilled the objectives as stated in the web seminar.

* 23. I learned as much or more than I expected.

* 24. The training format of the live and/or recorded web seminar was effective.

* 25. This training will help positively inform my professional practice or performance.

* 26. The session was well-organized.

* 27. The session slides were clear and legible.

* 28. The session length was appropriate for this session.

* 30. I verify that I attended the entire hour-long event and am eligible for one hour of continuing education credit.

* 31. I acknowledge and understand that IT WILL TAKE 30 days from the date of my application for my CEU credit to be issued to me.

* 32. Are you currently a member of ASA?

* 33. If you would like more information, please choose the appropriate box(es) below.

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