IMPORTANT NOTICE: CEU’s obtained through the American ...



IMPORTANT NOTICE: CEU’s obtained through the American Heart Assoc. (AHA), American Lung Assoc. (ALA) or the American Assoc. for Respiratory Care (AARC) may be directly submitted to Licensure Board.RETURN APPLICATION TO:New Mexico Society for Respiratory CarePO BOX 35417 Station DAlbuquerque, NM 87176-5417OR PREFERABLYNMSRC.CEU.APP@FOR OFFICIAL USE ONLY_____APPROVED_______________DENIED_____________DEFFEREDNMSRC Approval #________________DATEName of person approving CEUs___________________________________New Mexico Society for Respiratory Care Practitioner CEU Sponsor Questionnaire1. OFFICIAL NAME OF SPONSORING ORGANIZATION2. TELEPHONE NUMBER (include area code)EMAIL ADDRESS OF CONTACT:3. ADDRESS (include Street, City, State, and Zip Code)4. NAME OF PERSON RESPONSIBLE FOR CONTINUING EDUCATION PROGRAM(S)5. TITLE6. ADDRESS (include Street, City, State, and Zip Code)7. TELEPHONE NUMBER(include area code)8. PROGRAM TITLE9. PROGRAM DATE10. PROGRAM LOCATION11. CONTINUING EDUCATION HOURS APPLYING FOR: NOTE: One hour of Category I CE credit equals 60 minutes of instructional contact. Instructional contact does not include registration, breaks, or evaluation periods. We will round to the nearest quarter hour.12. TEACHING METHODS: [ ] Lecture [ ] Media [] Workshop []Clinical []Lab [] Other____________________________________Note: All Category 1 CE must be instructor-directed to encourage questions and discussion.13. A. Complete form A for each lecture/activity and attach to Program ApplicationB. Attach your program brochure or schedule of lectures to Program Application (electronic copy if you are emailing your materials in, hardcopy if you are using regular mail14. The undersigned, on behalf of the sponsor(s) agrees to: A. Assure that the program outlined will be conducted as proposed. B. Maintain attendance rosters and keep them for two years following completion of the program. C. Uphold standards for high quality continuing education activities.15. Signature of Program Coordinator/Chairperson DATE: This application will be reviewed within 15 working days from the day received by the NMSRC. If approved, a letter of notification and an attendance log form will be forwarded.NO APPLICATION WILL BE PROCESSED UNLESS COMPLETENMSRC.CEU.APP@ ................
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