_Test page for forms

Date of Application*

Course Title*

CEU Value requested*

.1 CEU = .1 Contact Hour

.1 CEU - 1 hour course (3 learning outcomes)
.2 CEU - 2 hour course (4 learning outcomes)
.3 CEU - 3 hour course (5 learning outcomes)
.4 CEU - 4 hour course (6 learning outcomes)
.5 CEU - 5 hour course (7 learning outcomes)
.6 CEU - 6 hour course (8 learning outcomes)
.7 CEU - 7 hour course (9 learning objectives)
.8 CEU - 8 hour course (10 learning objectives)

If you are requesting more than .8 CEUs, please contact the Education Manager, Kathy Fisher, at kfisher@nrrts.org

Name of Organization or Company*

The name of the company or organization that is hosting this course.

Name of Contact (Authorized Company Representative)*

First Last

Email*

Enter Email Confirm Email

Phone*

Company Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Marketing the Event

Marketing brochure or online promotion of the course(s) must include:

- Course description
- Learning outcomes
- Registration details
- Speaker bio, credentials

The following statement must also be included:

iNRRTSCE is certifying the educational contact hours of the program and by doing so is in no way endorsing any specific content, company, or product. The information presented in this program may represent only a sample of appropriate interventions. As an IACET Accredited Provider, The International Registry of Rehabilitation Technology Suppliers offers CEUs for its programs that qualify under the ANSI/IACET Standard. This course is approved for _____ CEU.

Upload a copy of the proposed marketing material related to the course.*

Max. file size: 50 MB.

Course Type*

Online learning events require a quiz with a minimum 5 Questions for each 1-hour course and 10 questions for a 2-hour course. Not required for Classroom Learning (face-to-face) Events.

Live Webinar with Quiz
On Demand Webinar with Quiz
In-Person Learning Event with Quiz
In-Person Learning Event No Quiz

Target Audience

Target Audience*

Hold CTRL key to for multiple selections

Needs Analysis - the need for this course was determined by*

Justification for this topic.*

Please describe the outcomes for each of the Needs Analysis items selected above.

Assessment Method and Performance Criteria

As stated earlier, online learning events require a CEU quiz with a minimum 5 Questions for each 1-hour course and 10 questions for a 2-hour course. A quiz is not required for Classroom Learning (face-to-face) Events. If you are NOT submitting a quiz with the application, please email it to snoelting@nrrts.org no later than three weeks prior to the event.

Upload CEU quiz*

Accepted file types: doc, docx, jpg, gif, png, pdf, Max. file size: 50 MB.

Please Select the Passing Score for this Quiz.

90%
80%
70%
60%

Speaker/Presenter Information

Will more than one speaker be approved to present this course?

Yes
No

Speaker 1 Name, Credentials, Bio*

Provide the speaker's professional qualifications to present this topic and include a short bio on each speaker describing their professional experience. If there are more than three (3) presenters, please complete this form with the first three presenters and contact Kathy Fisher, Education Manager, at kfisher@nrrts.org.

Speaker 1 Name	Speaker 1 Credentials

Speaker 1 Bio*

Speaker 2 Name, Credentials, Bio

Speaker 2 Name	Speaker 2 Credentials

Speaker 2 Bio

Speaker 3 Name, Credentials, Bio

Speaker 3 Name	Speaker 3 Credentials

Speaker 3 Bio

Communication Method*

How will learners, and others communicate with you, the speaker? This information must be provided before the learning event.

How will you document and verify attendance?*

Learning Designs

Enter the methods and the media used to present the learning outcomes.

Instructional method used to present the content for the following learning outcomes*

Power Point
Lecture
Discussion

Media used to support learning outcomes*

Handout
Images
Videos
Charts
Case Studies

Learning Outcomes

Learning outcomes must be expressed as specific and measurable objectives of the course being presented. The time allocated for each learning outcome must reflect the total course instruction time of a minimum of 50 minutes per .1 Continuing Education Unit. Learning outcomes must be presented at the beginning of the presentation,

Learning Outcome #1*