NJPA CE Submission Form: Affiliate Programs ONLY

This form MUST be completed in its entirety in order to be in compliance with APA Continuing Education Sponsorship Standards (Revised 8/3/2023).

THIS FORM MUST BE SUBMITTED 90 DAYS PRIOR TO THE EVENT DATE.

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* 1. CE Program Title

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* 2. CE Program Date

Program Date

Date

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* 3. Identification of number of Continuing Education Credits requested
1 credit per 60 minutes of instructional time and a clear indication of any activities within a program that are not offered for CE credit (examples: 8:00 am - 8:30 am networking and breakfast or 12:00 pm - 1:00 pm lunch break). PLEASE USE THE TERM CE. CEU IS GRANTED PER EVERY TEN HOURS OF CONTACT.

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* 4. Program Flyer (Must include Program Narrative & Learning Objectives)

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* 5. Contact Name & Email

Name

Email Address

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* 6. APA Standard B
APA Standard B requires that there is a direct input of psychologists in all phases of the decision-making and program planning process for the activities offered to psychologists for CE credit.

Please list the name(s) and contact information of the psychologist(s) involved in programming. Presenter/Participating Psychologist's Name, Contact Information, and Degree

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* 7. Evidence of Involvement of Psychologist: This only applies if the presenter is not a psychologist. Include this person's CV along with the instructor's CV.

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* 8. Instructor Curriculum Vitae:

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* 9. CV #2

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* 10. CV #3

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* 11. CV #4

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* 12. Program References:

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* 13. Diversity Requirement: How will you address diversity issues in your presentation?
Based on the APA Continuing Education Standards and Criteria and NJPA’s pledge to diversity and inclusion, we are committed to both selecting NJPA and NJPA co-sponsored continuing education program instructors and developing NJPA and NJPA co-sponsored program content that respects cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status. Please be sure to review the APA toolkit resources: https://www.apa.org/ed/sponsor/resources/understanding-addressing-diversity designed to support sponsors and applicants in addressing diversity in their CE programming. Presenters are expected to engage in a search for literature on how diversity impacts their program. Click below: https://njpa.memberclicks.net/assets/ce/Searches%20regarding%20diversity.pdf to review a link on diversity research. Examples of diversity within your presentation include, but are not limited to discussion of cultural factors on assessment and therapy, presentation of research on diverse groups, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status.

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* 14. Identification of Type of Activity:

Workshop - A program that is less than one week

Lecture Series - A program that is more than one week but less than six months

In-Depth Series - any program that lasts longer than six months

Conference - Where participants are required to attend all components. If one or more of the activities listed is part of a multi-session program for which credit is earned on a session by session basis, you should list the program as a session

Session - Individual programs within a conference that do not require full conference attendance

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* 15. Level of Learning Beyond the Completion of a Doctoral Degree

Introductory: no prior knowledge of the specific topic is required

Intermediate: some basic knowledge of the specific content is required

Advanced: substantial working knowledge or skill level in the specific content area is required

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* 16. Target Audience: Select ALL that apply

Psychologists

Psychatrists

Social Workers

Nurses

Physicians

Educators

Mental Health Counselors

Marriage and Family Therapists

Graduate Students

Undergraduate Students

Other (please specify)

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* 17. Evidence-Based Approach: Please check the box that best applies to your program:

Criteria D.1.1 Program content focuses on application of psychological assessment and/or intervention methods that have overall consistent and credible empirical support in the contemporary peer reviewed scientific literature beyond those publications and other types of communications devoted primarily to the promotion of the approach

Criteria D.1.2 Program content focuses on ethical, legal, statutory, or regulatory policies, guidelines, and standards that impact psychological practice, education, or research

Criteria D.1.3 Program content focuses on topics related to psychological practice education or research other than application of psychological assessment and/or intervention methods that are supported by contemporary scholarship grounded in established research procedure

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* 18. Identification of Conflicts of Interest and Commercial Support:
Any Conflicts of Interest and/or Commercial Support?
Co-sponsors must have a process to identify any potential conflict of interest and/or commercial support for any program offered, and they must clearly describe any commercial support for the CE program, presentation, or instructor to program participants at the time the CE program begins. Any other relationship that could be reasonably construed as a conflict of interest also must be disclosed. The promotional materials must disclose and the instructors must disclose and explain the presence or absence of commercial support or conflict of interest at the time the CE program begins.

Yes (Please Specify)

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* 19. Identification of Proprietary Information

When permission for use of proprietary information is required, NJPA and/or the instructor is required to obtain that permission in writing from the appropriate body, such as a test publisher. When a case study is presented in a workshop, which may or may not include test data, results or test items, any identifying information will be disguised in a generic manner and any test related material will likewise be disguised and collected at the close of the workshop.

Yes (Please Specify)

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* 20. Accuracy and Utility of the Materials Presented

Instructors shall discuss the accuracy and utility of the materials presented. More specifically, the program is based on the references provided, and it is one of a number of approaches to the particular content, or if it is experimental in nature, to specifically cite that, but not represent as the only approach. Instructors must discuss the possible limitations of the approach and the most common potential risks, as well as the most severe, if any. A disclaimer will be included in promotional materials that NJPA does not endorse the presented material as the only approach to a given area of study or therapeutic approach.

I agree

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* 21. Confidentiality

The principle of confidentiality of instructional materials and participant disclosure, if any, must be maintained. When applicable, the applicant will explicitly state at the beginning of the program that confidential material may be discussed and should review with the participants the limits of that confidentiality. See APA Ethical Principles of Psychologists and Code of Conduct 4.07.

I agree

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* 22. Disclaimer to Attendees (if deemed necessary)

Workshop participants should be informed if a presentation may be particularly stressful or upsetting at the beginning of the program or in the promotional materials, as deemed appropriate by the program sponsor.

I agree

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* 23. AI Usage
Has AI been Used for Any Part of the Presentation. If Yes, Please Confirm You Have Read and are In Compliance with APA CEC Interim Code of Conduct on Generative AI. Link to Code: https://www.apa.org/ed/sponsor/resources/continuing-education-policy-generative-ai.pdf

Yes, and confirm that the program is in compliance with APA CEC Interim Code of Conduct on Generative AI.

No, AI is not used.

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* 24. Please indicate the method you will use to submit payment for the affiliate application.

Online Payment (Click here to access the payment link)

Payment by Check

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* 25. I have read and complied with the terms listed above - Please type name, Title and/or Degree

Name

NJPA CE Submission Form: Affiliate Programs ONLY

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* 1. CE Program Title

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* 2. CE Program Date

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* 4. Program Flyer (Must include Program Narrative & Learning Objectives)

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* 5. Contact Name & Email

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* 7. Evidence of Involvement of Psychologist: This only applies if the presenter is not a psychologist. Include this person's CV along with the instructor's CV.

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* 8. Instructor Curriculum Vitae:

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* 9. CV #2

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* 10. CV #3

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* 11. CV #4

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* 12. Program References:

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* 14. Identification of Type of Activity:

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* 15. Level of Learning Beyond the Completion of a Doctoral Degree

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* 16. Target Audience: Select ALL that apply

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* 17. Evidence-Based Approach: Please check the box that best applies to your program:

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* 22. Disclaimer to Attendees (if deemed necessary)Workshop participants should be informed if a presentation may be particularly stressful or upsetting at the beginning of the program or in the promotional materials, as deemed appropriate by the program sponsor.

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* 23. AI UsageHas AI been Used for Any Part of the Presentation. If Yes, Please Confirm You Have Read and are In Compliance with APA CEC Interim Code of Conduct on Generative AI. Link to Code: https://www.apa.org/ed/sponsor/resources/continuing-education-policy-generative-ai.pdf

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* 24. Please indicate the method you will use to submit payment for the affiliate application.

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* 25. I have read and complied with the terms listed above - Please type name, Title and/or Degree

* 22. Disclaimer to Attendees (if deemed necessary)

Workshop participants should be informed if a presentation may be particularly stressful or upsetting at the beginning of the program or in the promotional materials, as deemed appropriate by the program sponsor.

* 23. AI Usage
Has AI been Used for Any Part of the Presentation. If Yes, Please Confirm You Have Read and are In Compliance with APA CEC Interim Code of Conduct on Generative AI. Link to Code: https://www.apa.org/ed/sponsor/resources/continuing-education-policy-generative-ai.pdf