Free 50713.FH11 - Indiana

APPLICATION FOR APPROVAL OF CONTINUING EDUCATION PROGRAMS FOR CHIROPRACTORS
State Form 50713 (R / 2-06)

INDIANA BOARD OF CHIROPRACTIC EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected] www.pla.IN.gov

FOR OFFICE USE ONLY
Date received / postmarked (month, day, year) Date of approval (month, day, year) Continuing education hours granted

DO NOT WRITE ABOVE THIS LINE
SPONSORING CHIROPRACTIC COLLEGE OR ORGANIZATION

Name of sponsoring college or organization Address (number and street, or post office box) City Telephone number

State E-mail address Website

ZIP code

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Name of course coordinator Mailing address (number and street, or post office box) City Telephone number

PROGRAM COORDINATOR

Title

State FAX number E-mail address

ZIP code

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PROGRAM TO BE OFFERED
Program title

Program Date(s)

Location of Program (City and State)

Number of continuing education hours requested per program date: CONTINUING EDUCATION HOURS REQUESTED FOR APPROVAL Please break down your program in the proper categories with the number of continuing education hours requested. CATEGORY DIAGNOSIS AND EXAM PROCEDURES PRINCIPLES OF PRACTICE PHYSICAL THERAPY / PHYSIOLOGICAL THERAPEUTICS NUTRITION ADJUSTIVE TECHNIQUE RADIOGRAPHIC TECHNIQUE / SAFETY (Continued on the reverse side) HOURS REQUESTED

CONTINUING EDUCATION HOURS REQUESTED FOR APPROVAL (Continued) Please break down your program in the proper categories with the number of continuing education hours requested. CATEGORY DIAGNOSTIC IMAGING INTERPRETATION BASIC SCIENCES RESEARCH TRENDS SCOPE OF PRACTICE RISK MANAGEMENT Insurance Reporting / Procedures Medical / Legal HIV Prevention / Education Boundaries Issues Public Health and Safety Documentation / Medical Records OTHER (SPECIFY): TOTAL NUMBER OF HOURS REQUESTED FOR APPROVAL PLEASE NOTE: The Indiana Board of Chiropractic Examiners has determined that courses in the areas of practice management, contact reflex analysis, acupuncture and philosophy are not acceptable for approval of continuing education hours. NAME OF INSTRUCTOR(S) Please list the names of instructor(s). Attach curriculum vitas or resumes. HOURS REQUESTED

VERIFICATION OF ATTENDANCE
Who will maintain adequate records of course participants and agree to provide participants with a record of attendance and to retain records of attendance by participants for four (4) years from the date of the program? What is the method of certifying attendance?

ADDITIONAL INFORMATION REQUESTED 1. Have you enclosed an original and a copy of the advertisement brochure and / or promotional materials, if used? 2. Have you submitted an original and a copy of the following information with your application: a. Course syllabus or outline of the material covered in the course giving specific times of lectures. b. A brief summary of the program content c. Date(s) of the program d. Location(s) of the program e. The number of hours requested. f. Indiana application for approval of continuing education. 4. Have you read and reviewed 846 IAC 1-8 regarding the approval of continuing education programs for chiropractors? APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date signed (month, day, year)

Yes

No Yes Yes Yes Yes Yes Yes Yes Yes

NA No No No No No No No No

3. Have you enclosed an original and a copy of the curriculum vitae and/or resumes of all instructors showing education and professional background?