November Sincerely, Janet D. Kusyk Janet D. Kusyk Continuing Education Coordinator

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1 November 2012 Thank you for your interest in obtaining continuing education credit for your event/workshop from the Oregon Chapter, NASW. Please refer to the Program Application Criteria in this packet to assist you in understanding the level of conference content and relevant social work topics if needed. The state of Oregon requires social workers practicing at the bachelors, masters and clinical/lcsw social work levels to seek licensure and continuing education. The NASW of Oregon certifies conferences and workshops in the continuing education categories of non- clinical, clinical, ethics and supervision. Please see the State Board of Licensed ers Oregon Administrative Rules Chapter 877 at Please complete the following Application for Professional Continuing Education Credit, including Attachment A: CEU Application Worksheet in its entirety. The CE application fee is different for profit and non- profit sponsors and is graduated according to the number of hours approved. Please call the office to discuss this non- profit rate or with questions. NASW will send an invoice to you. The CE application fee for a profit sponsor is: $190 for CE hours; $280 for 8-16 CE hours, $400 for CE hours, $450 for CE hours, $500 for CE hours, $630 for hours and $790 for CE hours. For a non- profit sponsor who is not charging for the conference, the CE application fee is: $95 for CE hours, $140 for 8-16 CE hours, $200 for CE hours, $225 for CE hours, $250 for CE hours, $315 for and $345 for CE hours. Please send applications by e- mail to Janet Kusyk at JK@nasworegon.org. Authorization typically takes four to six weeks from receipt of a completed application. A $75.00 rush fee will be added to any application needing authorization in less than 4 weeks time. The Chapter will review your application and contact you by e- mail with its determination. If your conference is approved, you will need to have attendees requesting CE credit complete an NASW conference evaluation form and sign a conference roster indicating their completion of the conference. Your approval letter, CE certificates, evaluation forms and conference roster will be e- mailed to you approximately two weeks prior to your event, time permitting. Your forthcoming approved conference/workshop will be posted on the NASW Oregon Web site if you request it on your application. If you wish to repeat this workshop (same speaker, content, etc.) within 12 months, there is a per repeated workshop fee of $50 for nonprofits and $80 for profit sponsors. JK@nasworegon.org with your request. It is the responsibility of the event/workshop sponsor to mail (please, do not e- mail or fax) attendance rosters and evaluations to the NASW office (2929 SW Multnomah Blvd., Ste. 204, Portland, OR, 97219) upon completion of the training. NASW will maintain these documents in its chapter files. Again, we appreciate your interest in the NASW Oregon Chapter s Continuing Education Program. Please contact our office at (503) if you have further questions. Sincerely, Janet D. Kusyk Janet D. Kusyk Continuing Education Coordinator jk@nasworegon.org

2 Application for Professional Continuing Education Credit Revised November 2012 For office use only: No. Fee $ Date Rec. / / PDF / / or / / Data Entry / / Date Paid / / Please save this as a PDF and send via to JK@nasworegon.org. Date of Application Prepared by Title of Event Sponsor(s) Event Date(s) Event Times Event Locations(s) City State Target Audience Will there be a registration fee(s)? Yes No Registration Fee(s) $ Registration Telephone ( ) Web site for registration inquiries Estimated number of attendees Total estimated number of CE hours requested for approval. Is this an "in service" (not open to other social workers) event? Yes Do you request this event be listed on the NASW Website? Yes No No 1. If diversity, cultural competence, social justice and/or anti-oppressive practice will be addressed, please describe how. Space below is limited to about 160 words. Please send attachment if you need more space. 2

3 2. Attach a brief agenda (including breaks and lunch) that includes dates and time frames for each agenda item or send a training flyer/brochure that carries this required information. 3. Attach a short paragraph () on each presenter describing the presenter's qualifications to present on his or her topic. Please include name, title, degrees, current and former work experience in topic area, etc. 4. Complete all information requested on 5. Please feel free to send additional information as a Microsoft Word document or PDF. Have you determined that the physical facilities for this event are ADA compatible for participants? Facilities are ADA compatible Not ADA compatible or undetermined as of this date Name Organization Address City State Zip Phone ( ) Fax ( ) Name Organization Address City State Zip Phone ( ) Fax ( ) After completing this form,including Attachment A, the CEU Application Worksheet,please both and any additional information to Janet Kusyk, jk@nasworegon.org. An invoice will be ed. Completed applications received less than four weeks before the training date will be assessed a rush fee of $75, which will be added to the application fee invoice sent by NASW. Application Fees and Payment Information on next page. 3

4 For a profit sponsor: $190 for CE hours; $280 for 8-16 CE hours, $400 for CE hours, $450 for CE hours, $500 for CE hours, $630 for hours and $790 for CE hours. For a non-profit sponsor who is not charging for the conference the CE application fee: $95 for CE hours, $140 for 8-16 CE hours, $200 for CE hours, $225 for CE hours, $250 for CE hours, $315 for and $345 for CE hours. Payment The chapter will send you an invoice for the application fee. Checks or money orders should be made payable to: Oregon Chapter, NASW and mailed to the chapter office, 2929 SW Multnomah Blvd., Suite 204, Portland, OR When sending additional material or a payment to NASW, the workshop s title and date should be clearly visible. If you wish to hold this workshop again within 12 months of the workshop date, there is a per repeated workshop fee of $50 for nonprofits and $80 for profit sponsors. Please call the chapter office at (503) for questions or information. Incomplete applications will not be processed until all information is received. Revised November

5 Attachment A: CEU Application Worksheet Page 1 of Training Title: Training Date(s): Worksheet Completed by: Tele. 1. Provide the start and end time for each workshop. 2. Non-Clinical Practice CEUs Number of hours with content pertaining to the practice of social work in general. 3. Clinical Practice CEUs Number of hours with content pertaining to the prevention, assessment, treatment or diagnosis of mental disorders. See page 2 of the Program Application Criteria for more information. 4. Ethics CEUs Number of hours with content pertaining to ethics, laws and administrative rules of practicing social work. 5. Supervision CEUs Number of hours with content pertaining to supervising the practice of social work. 6. Learning Objectives State how each workshop meets the objectives of each workshop s content. Time frame for each workshop 1 (Do not include time for introduction, breaks or lunch break) Speaker/Credentials/ Licensure Workshop Title & Brief Description Non-Clinical Practice # of CEUs 2 Clinical Social Work Practice # of CEUs 3 Ethics # of CEUs 4 Learning Objectives 6 (If you need more space, Supervision please send attachment.) # of CEUs 5

6 Attachment A: CEU Application Worksheet Page 2 of Training Title: Training Date(s): Worksheet Completed by: Tele. 1. Provide the start and end time for each workshop. 2. Non-Clinical Practice CEUs Number of hours with content pertaining to the practice of social work in general. 3. Clinical Practice CEUs Number of hours with content pertaining to the prevention, assessment, treatment or diagnosis of mental disorders. See page 2 of the Program Application Criteria for more information. 4. Ethics CEUs Number of hours with content pertaining to ethics, laws and administrative rules of practicing social work. 5. Supervision CEUs Number of hours with content pertaining to supervising the practice of social work. 6. Learning Objectives State how each workshop meets the objectives of each workshop s content. Time frame for each workshop 1 (Do not include time for introduction, breaks or lunch break) Speaker/Credentials/ Licensure Workshop Title & Brief Description Non-Clinical Practice # of CEUs 2 Clinical Social Work Practice # of CEUs 3 Ethics # of CEUs 4 Learning Objectives 6 (If you need more space, Supervision please send attachment.) # of CEUs 5

7 Attachment A: CEU Application Worksheet Page 3 of Training Title: Training Date(s): Worksheet Completed by: Tele. 1. Provide the start and end time for each workshop. 2. Non-Clinical Practice CEUs Number of hours with content pertaining to the practice of social work in general. 3. Clinical Practice CEUs Number of hours with content pertaining to the prevention, assessment, treatment or diagnosis of mental disorders. See page 2 of the Program Application Criteria for more information. 4. Ethics CEUs Number of hours with content pertaining to ethics, laws and administrative rules of practicing social work. 5. Supervision CEUs Number of hours with content pertaining to supervising the practice of social work. 6. Learning Objectives State how each workshop meets the objectives of each workshop s content. Time frame for each workshop 1 (Do not include time for introduction, breaks or lunch break) Speaker/Credentials/ Licensure Workshop Title & Brief Description Non-Clinical Practice # of CEUs 2 Clinical Social Work Practice # of CEUs 3 Ethics # of CEUs 4 Learning Objectives 6 (If you need more space, Supervision please send an attachment.) # of CEUs 5

8 Attachment A: CEU Application Worksheet Page 4 of Training Title: Training Date(s): Worksheet Completed by: Tele. 1. Provide the start and end time for each workshop. 2. Non-Clinical Practice CEUs Number of hours with content pertaining to the practice of social work in general. 3. Clinical Practice CEUs Number of hours with content pertaining to the prevention, assessment, treatment or diagnosis of mental disorders. See page 2 of the Program Application Criteria for more information. 4. Ethics CEUs Number of hours with content pertaining to ethics, laws and administrative rules of practicing social work. 5. Supervision CEUs Number of hours with content pertaining to supervising the practice of social work. 6. Learning Objectives State how each workshop meets the objectives of each workshop s content. Time frame for each workshop 1 (Do not include time for introduction, breaks or lunch break) Speaker/Credentials/ Licensure Workshop Title & Brief Description Non-Clinical Practice # of CEUs 2 Clinical Social Work Practice # of CEUs 3 Ethics # of CEUs 4 Learning Objectives 6 (If you need more space, Supervision please send an attachment.) # of CEUs 5