Free 50714.FH11 - Indiana

APPLICATION FOR APPROVAL OF CONTINUING EDUCATION PROGRAMS FOR OPTOMETRIST
State Form 50714 (1-06)

DATE RECEIVED / POSTMARKED (month, day, year) APPROVAL DATE (month, day, year) CONTINUING EDUCATION HOURS GRANTED SPONSORING ORGANIZATION

INDIANA OPTOMETRY BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2054 E-mail: [email protected]

Name of sponsor Address (number and street, or post office box) City Telephone number Fax number

Type of organization

State E-mail address Website

ZIP code

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PROGRAM COORDINATOR
Title

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

State Fax number E-mail address

ZIP code

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Title

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PROGRAM TO BE OFFERED

Date(s)

Location (city and state)

Number of Continuing Education Hours Requested Per Date TYPE OF PROGRAM Conference Seminar Short Course Institute Workshop Grand Rounds Special Training Program Other ___________________________________

NAME OF INSTRUCTOR(S) Please list the names of instructor(s). Attach curriculum vitas or resumes. NAME OF LECTURER ACADEMIC AND PROFESSIONAL BACKGROUND

(Continued on the reverse side)

NAME OF INSTRUCTOR(S) (continued) Please list the names of instructor(s). Attach curriculum vitas or resumes. NAME OF LECTURER ACADEMIC AND PROFESSIONAL BACKGROUND

OBJECTIVES List the objectives for the continuing education course.

CONTENT OF PROGRAM Provide the Board with a brief summary of the content of the program below. Attach a copy of the program outline or brochure with time frames to this application.

RECORD OF ATTENDANCE
Who will monitor attendance? What is the manner in which attendance will be monitored? 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?

Does the Record of Attendance that will be awarded to the optometrist state the following: a. Sponsor of the program? Yes No b. Name of program? Yes No c. Date of the program? Yes No d. Number of continuing education hours awarded? Yes No NOTE: Each participant must be provided a record of attendance. ADDITIONAL INFORMATION REQUESTED 1. Have you enclosed the following items: a. One (1) original and one (1) copy of your application for continuing education approval. b. One (1) original and one (1) copy of the program outline or brochure with time frames. c. One (1) original and one (1) copy of the curriculum vitas or resumes of all lectures. 2. Have you applied for continuing education approval with any other entity? If yes, please specify: 3. Have you read and reviewed 852 IAC 1-16 regarding the approval of continuing education programs for optometrists? 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 program coordinator Date signed (month, day, year)

Yes Yes Yes Yes

No No No No

Yes

No