Practical Continuing Education verification form

 

 

 

COMPLETION INSTRUCTIONS

 

The following information is to be used for the completion of your practical experience CE hours.  Please read all the enclosed materials before submitting your hours. Reviewing these guidelines will help to ensure your submitted hours will be accepted.

 

1.         Enclose a brief typewritten report on each portion of your practical experience, containing information on what you observed or treated and attach it.

 

            2.         Make sure that you have proper verification of the hours.  See the attached sheet for further information on the verification process.

 

            3.         CEUs will be calculated as 0.25 CEU per hour of active participation with a maximum of 50% of the annual CE requirement allowed per year. (i.e. 4.0 hours of active participation equals 1.0 CEU.)

 

            4.         Send your completed documentation to:

 

                         ACBSP™

                         103 SOUTH 6TH STREET

                         ESTHERVILLE, IA 51334-2325

 

 

Field Doctor Verification Form

 

NAME

ADDRESS

CITY

OFFICE PH

STATE

HOME PH

ZIP CODE

CERTIFICATE #

CERTIFICATION DATE            

 

 

                                                         PRACTICAL EXPERIENCE VERIFICATION

 

I verify that the information that I have submitted concerning my practical experience hours is true and correct. I understand that if any false information has been included, my postgraduate degree may be withheld.

 

 

SIGNED     ________________________________________________________ DATE __________________

 

TYPE NAME ______________________________________________________________________________

 

                                         SPORTS EVENT FIELD DOCTOR PARTICIPATION FORM

 

 

 

NAME ___________________________________________________ PHONE __________________________ 

 

ADDRESS _____________________________________________ STATE _______ ZIP CODE _____________

 

EVENT ___________________________________________________________________________________ 

 

DATE _____________________________________ # OF HOURS____________________________________

 

RESPONSIBILITIES____________________________________________________________________________

 

________________________________________________________________________

 

________________________________________________________________________

 

EVENT COORDINATOR SIGNATURE______________________________________ DATE _______________ 

 

EVENT COORDINATOR COMMENTS___________________________________________________________

 

_____________________________________________________________________________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           

_____________________________________________________________________________________________

 

_____________________________________________________________________________________________

 

_____________________________________________________________________________________________

 

_____________________________________________________________________________________________

 

Please note:  Sports administrators, athletic directors and school principals are authorized to verify participation.  Coaching staff are not authorized to do so.  Please feel free to copy this sheet as often as needed.