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 = 1.0 CEU.)

 

4.         Send your completed documentation to:

 

                         ACBSP™

                         103 SOUTH 6TH STREET

                         ESTHERVILLE, IA 51334-2360

 

 

   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.