Free 50323.FH11 - Indiana

APPLICATION FOR APPROVAL OF CONTINUING EDUCATION PROGRAMS FOR RESPIRATORY CARE PRACTITIONERS
State Form 50323 (R / 2-06)

RESPIRATORY CARE COMMITTEE PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room 072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected]

INSTRUCTIONS:

Please type and answer all questions. 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 ORGANIZATION
Name of Sponsoring Organization Address (number and street or post office box) City Telephone number (daytime) E-mail address State ZIP code

(

)

PROGRAM COORDINATOR
Name(s) of Course Coordinator(s) Mailing address (number and street or post office box) City Telephone number (daytime) E-mail address State ZIP code Title

(

)

PROGRAM TO BE OFFERED
Program title Program date(s) Location of program (city and state) Number of Continuing Education hours requested

One Program Multiple Programs

TYPE OF PROGRAM

Conference Seminar Short Course

Institute Workshop Videotape
OBJECTIVES

Special Training Program Satellite Program

List the objectives for the continuing education course.

Page 1 of 3

ADMINISTRATION Who planned the overall program?

Who will maintain adequate records of course participants and certify to their accuracy?

What is the anticipated enrollment?

CURRICULUM List the curriculum by subject areas, the continuing education hours planned, the faculty members, and the proposed method of presentation for each subject area. SUBJECT HOURS FACULTY METHOD OF PRESENTATION

FACILITIES At what type of facility will the course be conducted?

List any clinics, hospitals, or other organizations involved in the training program, if applicable.

EDUCATIONAL METHODOLOGY Check the educational methods being employed in the course.

Laboratory Experience Question-Answer Period
What teaching aids will be used? (Check applicable spaces.)

Lectures Group Discussion

Videos - Year Produced? ________ Charts Television

Blackboard

Slides

Overhead Projectors

Other: _______________________________________________________________________
If the group is to be divided for some of the course, list the approximate size and the type of method to be employed.

EVALUATION What type of evaluation will be conducted to measure the programs content and effectiveness? (Please submit copy of proposed evaluation.)

Will an evaluation be made by the individual participant? If so, how?

Page 2 of 3

EVALUATION (Continued) How will the evaluation be used to improve future course offerings?

Does the Certificate of Attendance that will be awarded to the respiratory care practitioner state the following: 1. Sponsor of the program? 2. Name of the program? 3. Date of the program? 4. Number of continuing education hours awarded? Yes Yes Yes Yes No No No No

NOTE: Each participant must be provided a certificate of attendance.

ADDITIONAL INFORMATION REQUIRED 1. Have you enclosed the following items: a. One (1) original and one (1) copy of the program brochure or a draft copy of the information to be provided in the brochure? b. One (1) original and one (1) copy of the evaluation form? c. One (1) original and one (1) copy of your application for continuing education approval? 2. Have specific time intervals been specified for each activity in the brochure? 3. Has the content of the program been documented and included with the application? 4. If the program is a multiple day program have you indicated on which day each topic will be presented? 5. Have all faculty member / speakers presenting the program been identified by name and title? 6. Is this program a videotape? If yes, please provide specific dates the videotape will be shown and the date the videotape was originally produced. Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No

Page 3 of 3