HSPA | CE Approval Request Form

CE Approval Request

Progam Overview

Is this a renewal?

Previous HSPA/IAHCSMM Approval Code

Sponsoring Organization

Program Title

Program Location

Program Dates

Number of CE Credits Requested

Delivery Method

You may choose multiple methods. At least one selection is required.

Speakers

Please list each speaker, topic, objective and length of time. Clear objectives and time allocation for each topic must be submitted. A minimum of one speaker, topic, objective and time must be listed.

Speaker 1

Speaker Name

Topic

Objective

Presentation Duration

Additional Information

Contact Info

Name

Phone (123-555-4567)

Address

City

State/Province

Zip/Postal Code

Supporting Documents

Submission Requirements

Lectures and Conferences: Include a sample brochure and/or handout, that clearly outlines the program title(s), objectives and number of contact hours planned for each topic
Print and Online Publications: Include a copy of the article or module and the post--test, if applicable
Presentation and In-Services: Include a copy of the handout, outline or PowerPoint presentation (in PDF format) that will be used and the post--test, if applicable.

We highly recommend that your files be either in PDF (.pdf) or Microsoft Word format (.doc, .docx) and not exceed 5 MB total.

Upload a file