A. Submitter Information
Official authorization notice will be emailed to the below email address. The submitter listed below will be contacted by the Collaborative if there are any questions about the application form.
B. Sponsor Information
List the name of the
sponsoring organization or individual below. If you are an individual sponsoring a program Submit these items below. independent of any organization and this is your FIRST time applying online, you MUST submit a resume and two letters of reference regarding your qualifications and relevant experience.
Briefly describe what kind of work the sponsor does.
Has your organization been approved as a continuing education provider or had program approval with other professional associations?
If yes, list the full titles of the organizations below.
Has your organization been denied approval as a continuing education provider or had a program denied approval?
When was the program created?
learning (not teaching) objectives below.
Type the length of each activity. For readings, type the word count. For audio/visual activity, type the length of time.
Total the above activity time lengths. CEs will be rounded down to the nearest whole or half number.
Select the program's targeted social work practice levels.
Advanced Practitioner Intermediate Practitioner Beginning Practitioner
Select the type of distance learning program.
Home study publication or online article DVD or Videotape Audio (Audiotape, CD, MP3 Podcast, etc.) Other (please specify)
Describe how the course content applies to clinical and/or macro social work practice.
List three (3) books or articles of reference from the bibliography.
D. Instructor Information
In the box below, type the following information for EACH instructor.
Number each instructor.
Degrees and License
Brief description of Relevant Experience – No more than one paragraph per instructor. (DO NOT COPY AND PASTE RESUMES INTO THIS BOX.) Note: If you uploaded a program brochure with this information, type "see brochure" below.
E. Distance Learning Specifics
Distance learning providers may be requested to send one copy of their program (i.e. videotape, book, etc.) to the Collaborative.
Do NOT send this material unless it has been requested by the Collaborative.
If you are offering an Internet course, please type the course website address and any relevant login information below.
Do you take security measures to protect participants’ personal information?
Security measures are taken to protect participants’ personal information.
Describe the procedure and timetable for RECEIVING (fax, email, or mail), GRADING, and RETURNING (fax, email, or mail) post-tests and/or assignments.
Describe the procedure (fax, email, or mail) and timetable for evaluations to be turned in.
How does a participant contact the program’s designated person in case of problems or questions?
Upload a copy of the post-test (questions and answers) used in your program here. (Post-tests are required for distance learning)
What is the passing score?
As the approved sponsor, you are responsible for the creation and distribution of the certificates of attendance to participants who complete the program. Certificates MUST have the participant’s name on it before it is stamped/authorized and given out. Describe the procedure and timetable for issuing certificates of completion to course participants.
The evaluation form MUST list the program’s learning objectives in order to ascertain that teaching goals have been reached. Evaluation must be specific, written and measurable, and reflect the following areas:
(individual objectives must be rated) Course appropriateness to participant’s education, experience and licensure level
Relevance to professional practice and currency of information
Instructor’s knowledge of subject matter and responsiveness to participants
(if applicable) Was subject matter presented effectively and clearly?
Instructor’s ability to utilize course-appropriate technology to support participant learning
(if applicable) Suitability and/or usefulness of instructional materials
Location, facilities, and technology
Administration of the program
Timeline of course adhered to the advertised
We have an evaluation form for this program that meets the above requirements.
Please note that application(s) will NOT be reviewed until payment has been received by the Collaborative.
How are you paying for this form?
I am paying online with a credit card. I am sending payment via mail.