NAHUC
CONTACT
HOURS
PROGRAM
APPLICATION
PACKET
National Association of
Health Unit Coordinators, Inc.
1947 Madron Road
Rockford, IL 61107-1716
815-633-4351
888-22-NAHUC
(f) 815-633-4438
e-mail: office@nahuc.org
www.nahuc.org
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For Office Use Only |
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Program ID # |
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Date Received |
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Approved |
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Not Approved |
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Revised 01/05
Required Application
Documentation and Fee Schedule
To apply for NAHUC contact hours, submit the
following documents to NAHUC.
Keep a copy for
your records.
·
NAHUC
Contact Hours Program Application (below)
·
NAHUC
Continuing Education Program Information (page 2)
·
Curriculum
vita or biography of each speaker (sample on page 3)
·
A
copy of the evaluation tool (sample on
page 4)
·
Application
fee payable to NAHUC (see fee schedule below)
Submit the completed
application materials and appropriate fee to the NAHUC Education Board via the
NAHUC office at least 21 days prior to the program start date. The application will not be processed if
postmarked less than 21 days prior to program date. You will be notified upon receipt of
application. If you have not received
acknowledgment of receipt within 14 days after mailing, please contact the
NAHUC office.
Notification of approval or denial will be
sent prior to program date. If
approved, contact hours will be mailed to you prior to program date. Brochures published prior to the review may
indicate: "Approval for NAHUC Contact Hours Pending."
The application fees (nonrefundable) are as
listed and must accompany the application materials:
Postmarked 40 days or more in advance of
program date: $ 30.00
Postmarked 39-21 days in advance of program
date: $ 45.00
Program
Title_________________________________________________________________________
Program Coordinator’s Name
____________________________________________________________
Phone (daytime)_________________________ E-mail address ________________________________
Address______________________________________________________________________________
City_________________________________________
State__________Zip ______________________
Sponsoring Agency (if
applicable)_________________________________________________________
Location of Program
(facility)____________________________________________________________
Program Location Address_______________________________________________________________
Anticipated Number of
Participants________________________________________________________
Number of Contact Hours Applied For __________ (see contact hour calculation on page 2)
Signature of Program Coordinator______________________________________
Date _______________
Information
for numbers 1, 2, and 3 should be submitted on a separate page or may be
submitted on a printed brochure.
1. Program Learning Objectives
2. Format and Time Schedule. Show exact times using clock hours (i.e. 9 AM ‑ 10 AM) of each program topic/activity.
3. List of Speakers. List only speakers' names
and topics.
NAHUC contact hours are based on 50‑minute
hours. Contact hour calculations are determined by dividing the total number of
minutes of education provided by 50. Do
not include time devoted to any non-educational activities such as
registration, welcome, breaks, meals, business meetings, etc. The following example will assist you in
proper calculation.
8:00 ‑ 8:30 Registration
(no contact hours)
8:30 – 10:00 Burnout
‑ Its signs, symptoms, and prevention by Joe Smith, Ph.D.
10:00 ‑ 10:15 Break (no contact hours)
10:15 ‑ 11:15 Decompression ‑ Its Methods
and Values by Jane Ayre, MSW
11:15 ‑ 11:45 Stress Level Assessment and
relaxation skills by Jane Ayre, MSW
11:45 ‑ 12:00 Q & A
Contact Hour Calculations
8:00 am to 12:00 pm = 4
hours = 240 minutes
Subtract Registration -30 minutes
Subtract
Break ‑ 15 minutes
Balance of Continuing Ed
time 195 minutes
195 minutes divided by 50
minutes = 3.9 contact hours
Reapplication
Process
Program approval will be
granted for a maximum of one NAHUC fiscal year. All program approvals expire annually on April 30. If a program is repeated before April 30, no
additional fee is required to award contact hours. If program is to be repeated
before April 30, submit a letter to the NAHUC Education Board at 21 days prior
to offering the program stating:
·
Original
title and Program ID number
·
New
presentation date
·
Location
·
Anticipated
number in attendance
If any aspect of the program
changes, (e.g. different instructors, change in length of program etc.) a new
application must be submitted and a program fee is required.
Annual reapplication must be made if the program is offered in subsequent years.
Curriculum Vitae Sample
Name___________________________________________________________________
Address_________________________________________________________________
City________________________________________
State_______ Zip ____________
Work Phone______________________________ Work
Fax_______________________
Work E-mail
_____________________________________________________________
Present Position _________________________
Institution/Facility _________________
Qualifications
pertinent to this program
C. Titles of Prepared
Speeches/Presentations/Workshops
A
formal curriculum vita (CV), biography, or this form must be provided for each
speaker. If CV information is printed
on program brochure, brochure can be submitted instead of CV form.
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NAHUC Workshop Evaluation Tool Sample |
You must complete this form to receive contact hours for this seminar. Evaluate each program and presenter. Your response and comments are greatly appreciated. Thank you.
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Program
Title: Presenter Name: Date:
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Learning Objectives Upon completion of this program the participant
should be able to: |
Please mark the
appropriate bubble next to each item that expresses your evaluation of the
Program and Presenter. |
Strongly Agree |
Agree |
Neutral |
Disagree |
Strongly Disagree |
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1) 2) |
1. The program met the stated objectives |
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2. The program increased my knowledge/skills |
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3. The program content was organized & complete |
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4. The information was appropriate to my needs |
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5. The instruction method was suitable |
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6. The presenter was able to communicate and relate the material
effectively |
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7. The time for questions/discussion was adequate |
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Comments: |
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Program
Title: Presenter Name: Date:
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Learning Objectives Upon completion of this program the participant should
be able to: |
Please mark the
appropriate bubble next to each item that expresses your evaluation of the
Program and Presenter. |
Strongly Agree |
Agree |
Neutral |
Disagree |
Strongly Disagree |
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1) 2) |
1. The program met the stated objectives |
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‚ |
ƒ |
„ |
… |
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2. The program increased my knowledge/skills |
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‚ |
ƒ |
„ |
… |
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3. The program content was organized & complete |
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‚ |
ƒ |
„ |
… |
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4. The information was appropriate to my needs |
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‚ |
ƒ |
„ |
… |
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5. The instruction method was suitable |
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‚ |
ƒ |
„ |
… |
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6. The presenter was able to communicate and relate the material
effectively |
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ƒ |
„ |
… |
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7. The time for questions/discussion was adequate |
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ƒ |
„ |
… |
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Comments: |
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Please indicate the
benefit(s) you have gained from attending this program. (Check all that apply)
___ new knowledge ___ sharing ideas with others ___ change in perception
___ change in
attitude ___ new skills ___review only
Future Topics/Speakers:
Overall Comments: