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Documenti di Cultura
Speech-Language-Hearing
Association
Application
to
Co-Sponsor
Continuing
Education
Activities
The
Wyoming
Speech-Language
Pathology
and
Audiology
Association
(WSHA)
will
individually
administer
co-sponsorship
of
CE
activities
that
meet
ASHA
required
guidelines.
All
events
and
topics
must
conform
to
ASHA
guidelines
for
professional
or
related
content.
Speaker
must
possess
professional
qualifications.
The
focus
of
the
activity
must
not
be
for
the
sale
of
a
specific
product.
Please
contact
the
WSHA
CE
Administrator
as
soon
as
you
begin
planning
your
event
so
we
can
assist
you
with
the
necessary
ASHA
requirements.
Instructions:
Respond
to
each
of
the
questions
below
and
attach
required
information.
Course
and
Offering
Registration
Form
and
required
attachments
must
be
received
a
minimum
of
90
days
prior
to
the
event.
Shorter
time
frames
are
submitted
to
ASHA
as
exceptions
and
can
be
negotiated
with
the
CE
Administrator.
Detailed
instructions
and
additional
forms
are
available
on
the
WSHA
website
(www.wyomingspeechlanguagehearingassociation.org).
Contact
Person:
Address:
Contact
Phone:
Contact
Email:
Contact
relation
to
the
organization/company
offering
the
activity:
Organization/company
offering
CE
activity:
Expected
attendance:
Attendee
cost
for
activity:
Location
of
the
activity:
Beginning
date
of
activity:
Ending
date
of
activity:
Total
CEUs
offered:
Total
hours
offered:
(60
minutes
or
1
contact
hour
=
0.1
CEU,
time
does
not
include
breaks)
Course
Title
(not
to
exceed
60
characters):
Course
Description
(not
to
exceed
300
characters):
Subject
Code
(click
on
one
check
box):
1010
Fluency
Disorders
-
Assess
and
Intervention
1020
Voice
Disorders
-
Assess
and
Intervention
1030
Motor
Disorders
of
Speech
-
Assess
&
Intervention
1040
Dysphagia
-
Assess
and
Intervention
2010
Speech
Science
3010
Lang
Disorders
-
Assess
&
Intervention
3030
Lang
Disorders
-Aphasia
and
Acquired
Neurogenic
Disorders
&
Cognition
3040
Language
Disorders
-
AAC
3050
Language
Disorders
-
Articulation
4010
Language
Science
5010
Audiology
-
Assessment
5020
Audiology
-
Habilitation/Rehabilitation
5030
Hearing
Assistive
Technology
5040
Industrial
Audiology/Hearing
Conservation
6010
Hearing
Science
7010
Service
Delivery
assoc
with
Sp/Lang/Hearing
7015
Pre-professional
Education
Assoc
with
Sp/Lang/Hearing
7020
Education/Training
issues
in
Sp/Lang/Hearing
7025
Regulatory
Issues
in
Sp/Lang/Hearing
7030
Cultural
and
Linguistic
Diversity
in
Education
&
Public
Policy
7040
Psycho-social
Issues
in
Assess
&
Intervention
7050
Leadership
and
Management
in
Profess
Practice
Setting
7060
Patient
Safety
and
Prevention
of
Medical
Errors
8010
Microcomputer
and
Technology
9010
Speech-Language
Conferences
with
Multiple
Sessions
9015
SLP
Self
Study
or
Journals
9020
Audiology
Conferences
w/
multi
sessions
9025
Audiology
Self
Study
or
Journals
9030
Audiology
and
SLP
Conferences
with
multiple
sessions
9035
Audiology
and
SLP
Self
Study
or
Journal
9040
Review
Courses
for
National
Exam
in
SLP
or
Audiology
Content
Code
(click
on
one
check
box):
Basic
Communication
Processes
Professional
Related
Instructional
Level
(click
on
one
check
box):
Introductory
assumes
little
or
no
familiarity
with
the
area
Intermediate
assumes
general
familiarity
with
the
area
Advanced
assumes
thorough
familiarity
with
the
area
Various
single
level
cannot
be
determined;
multiple
sessions
Type
of
Activity
(click
on
one
check
box):
Workshop
2
Seminar
3
Conference
4
Forum
5
Symposium
6
In-service
7
Journal
Group
8
Study
Group
9
Grand
Rounds
10
Teleconference
11
Videoconference/Satellite
TV
12
Self
Study:
Video
or
Course
13
Self
Study:
Journal
or
newsletter
14
Convention
15
Short
Course
16
Miniseminar
17
Technical
Session
18
Poster
Session
19
Roundtable
Discussion
20
Traditional
academic
courses
22
Independent
study
23
Web-based
courses
List
course
offerings
on
Course
Search
on
ASHA
website?
Yes
No
If
yes,
please
provide
contact
name
and
phone
number
or
web
address,
etc.:
Course
CEUs
Attach
a
copy
of
the
time-ordered
agenda
that
lists
the
activitys
schedule
by
time
periods
including
content,
instructional
personnel,
etc.
Can
participants
achieve
the
entire
courses
learning
outcomes
without
full
attendance?
(Is
partial
credit
an
option)?
No
(continue
to
promotional
materials
section)
Yes
(respond
to
the
following)
How
will
course
participants
who
do
not
attend
the
entire
course
demonstrate
achievement
of
the
course
learning
outcomes?
(check
one):
The
course
has
multiple
sessions
and
each
session
has
discrete
learning
outcomes
that
are
assessed
at
the
end
of
each
session.
The
course
is
a
series
of
sessions.
Participants
must
attend
a
minimum
of
sessions.
A
passing
score
on
an
exam
is
the
satisfactory
completion
requirement.
Participant
will
successfully
demonstrate
a
skill
as
the
satisfactory
completion
requirement.
Other
(please
describe):
Disclosures
and
Promotional
Materials
The
Wyoming
Speech-Language
Hearing
Association
requires
that
all
individuals
involved
in
developing
and
delivering
course
content
to
be
offered
for
ASHA
CEUs
disclose
relevant
financial
and
nonfinancial
relationship(s).
Sample
disclosure
statements
can
be
found
by
clicking
on
the
following
link:
http://www.asha.org/CE/for-providers/admin/Sample-Disclosure-Statements/
Attach
a
copy
of
the
disclosure
form
for
all
planners
and
presenters.
Attach
a
copy
of
the
promotional
materials
including
course
advertisement,
which
includes
the
following:
1.
The
ASHA
CE
Approved
Provider
Brand
Block
and
CEU
sentence
(Contact
the
WSHA
CE
Administrator
for
a
copy
of
the
ASHA
CE
Approved
Provider
Brand
Block
by
emailing
the
WSHA
CE
Administrator:
djseabeck@gmail.com)
2.
Instructional
personnel
disclosure(s)
3.
Disclosure
that
the
course
is
focused
on
a
specific
product
or
service
and
there
will
be
no
or
limited
information
about
similar
products
or
services
(if
applicable).
4.
Disclosure
of
the
names
of
organizations
contributing
financial
and
in-kind
support
(if
applicable).
Prior
to
the
course,
did
you
disclose
that
the
course
content
was
focused
on
a
specific
product
or
service?
Yes
Not
applicable
Prior
to
the
beginning
of
the
course,
will
you
disclose
financial
and
in-kind
support
given
by
other
organizations
used
to
pay
for
all
or
part
of
the
costs
of
the
CE
course?
Not
applicable
Yes,
disclosure
is
made
in
promotional
materials
for
all
instructional
personnel.
Yes,
disclosure
will
be
made
at
the
start
of
the
course
for
all
instructional
personnel.
Course
Design
Needs
Assessment
Process
(check
all
that
apply):
Interviewed
key
individuals
Conducted
focus
group(s)
Surveyed
sample
population
Other
(please
describe):
Learning
Outcomes
Describe
the
skills,
knowledge
and/or
attitudes
(learning
outcomes)
participants
will
be
able
to
demonstrate
as
a
result
of
this
activity.
These
must
be
measurable
such
as:
participants
will:
demonstrate
or
describe
or
identify,
etc.
Attach
courses
learning
outcomes
Assessment
of
Learning
Process
(check
all
that
apply):
Performance
demonstrations
Written
report
Written
examination
Oral
report
Oral
examination
Self-assessment
Question
and
answer
session
Other
(please
describe):
Instructional
Methodology
(check
all
that
apply):
Lecture
Small
group
activity
Video
or
audio
presentation
Panel
discussion
Demonstration
of
procedures
Observation
of
patients
Case
study
Simulations
Other
(please
describe):
Planning
and
Instructional
Personnel
It
is
important
instructional
personnel
meet
ASHA
requirements.
Visit
the
ASHA
website
for
resources
on
the
following:
Evidence-Based
Continuing
Education
Tutorial
Guidance
on
Infusing
Evidence
into
CE
Course
Content
For
additional
assistance,
please
contact
the
WSHA
CE
Administrator:
Diana
Seabeck
307-742-7956
djseabeck@gmail.com
Satisfactory
Completion
and
Course
Evaluation
How
will
you
determine
whether
participants
meet
the
courses
satisfactory
completion
requirements
and
are
eligible
to
earn
CEUs?
(check
all
that
apply):
Attendance
Attainment
of
learning
outcomes
Fees
Attach
a
$325
ASHA
processing
fee
to
this
form
plus
attachments:
Check
enclosed
payable
to
American
Speech-Language-Hearing
Association
(ASHA)
Credit
Card
Visa
Mastercard
Credit
Card
Number:
Expiration
Date:
Authorized
Signature:______________________________________________
Return
the
completed
Continuing
Education
Activity
Approval
Worksheet,
required
attachments,
and
fees
by
US
mail
to:
WSHA
CE
Administrator:
Diana
Seabeck
2533
Park
Avenue
Laramie,
WY
82070
OR
by
email
with
attached
documents
to
djseabeck@gmail.com
Timeframe
In
accordance
with
ASHA
timeframes,
the
above
requested
information
must
be
received
by
the
WSHA
CE
Administrator
at
least
90
days
prior
to
the
event.
Timeframe
exceptions
may
be
negotiated
with
the
administrator.