Contact Hour Application

Application Instructions

Please complete the application below for ICEA contact hours. If approved, you will be invoiced $25 per contact hour awarded. If you have any questions, please contact info@icea.org/.

Applicant or Organization Information

Applicant/Organization Name

Applicant/Organization Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Contact Information

Name*

First Last Credentials

Email*

Telephone Number*

Educational Activity Information

Activity Title*

Activity Date*

Number of Total Activity Hours*

Include all time for introductions, breaks, meals, and non-CE content time.

Number of Contact Hours to be reviewed by ICEA and offered as ICEA Contact Hours*

Activity Type (choose one)*

Blended Activity Details

Please provide the specific methods being used in the activity.

Learning Outcomes and Objectives*

Provide at least three outcomes or objectives that are included in the activity brochure. What will the outcome be as a result of participation in this activity? Objectives should realistically state what the participant can learn in the activity. Use words such as “list’ identify, describe, compare, explain,” to describe what the participant will be able to do upon completion of the activity.

Activity Outline/Agenda*

Provide details on the outline/agenda of the activity which develops the above objectives. Include introductions, breaks, meals and non-CE content time. Time spent evaluating the learning activity may be included in the contact minutes when calculating contact hours.

Time Allotment (in minutes)	Session Title	Speaker Name and Credentials	Content (Topics)

Teaching Methods to be used (check all that apply)*

Other Teaching Methods

Please provide details on what other teaching methods are to be used in this activity.

Learner Engagement Strategies (check all that apply)*

Integrating opportunities for dialogue or question/answer
Including time for self-check or reflection
Audience response system
Analyzing case studies
Providing opportunities for problem-based learning
Pre/Post-test
Other

Other Learner Engagement Strategies

Please provide the other learner engagement strategies to be used.

Please list three current resources for activity topics that are no more than 5 years old:*

#1	#2	#3

Speaker Information

Curriculum Vitae (CV) for each Speaker

Upload a CV for each activity speaker.

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 800 MB, Max. files: 5.

Speaker Disclosure and Conflict of Interest Declaration*

It is the policy of the ICEA to make best efforts to insure balance, independence, objectivity, and scientific rigor in all programs which qualify for Contact Hours. Consequently, all speakers/presenters participating in any program for which Contact Hours are awarded are expected to disclose to the program audience any affiliations that may have a bearing on the subject matter of their presentation. The intent of this policy is to ensure that any real or potential conflict of interest shall be identified openly so that listeners may form their own judgments about the presentation with the full disclosure of pertinent facts. It remains for the audience to determine whether the speaker’s outside interests may reflect a possible bias in the information presented.

As the Program Provider, I understand my responsibility in distributing, collecting, and retaining the Speaker Disclosure & Conflict of Interest Declaration Forms from each speaker on the Activity Outline/Agenda. Furthermore, I understand it is my responsibility to print any disclosures made by the speakers in the program materials and to provide ICEA with copies of the completed disclosure forms.

Collection & Submission of Speaker Disclosures & Conflict of Interest Declarations*

As the Program Provider, I understand that ICEA will send the primary contact an email with a link to the Speaker Disclosure & Conflict of Interest Declaration, which should then be forwarded to all program speakers and request that the form be submitted to ICEA by the program date(s).

Application Review Fee & Submission Process