CONTINUING EDUCATION APPROVAL REQUEST FORM

Submit this request at least thirty (30) days prior to presentation of the program. In order to be eligible for approval, the program(s) must be open to all administrators and must relate to nursing home administration (See the Domains of Practice).

Sponsors are responsible for monitoring attendance and furnishing each participant with evidence of attendance.

Name and address of requesting sponsor:
*Sponsor
*Address
Address 2
*City
*State	Select Alabama Alaska Arkansas Arizona California Colorado Connecticut Washington, DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
*Zip
*Email
*Program Title
Provide the phone number and web site address, if available, to be published on our web site for individuals wanting to register for the program.
*Phone	Ext.
Web Address	www.
*Total in-person program education hours (1 clock hour = 1 CE hour):
*Total distance learning program education hours (1 clock hour = 1 CE hour):
*Total Program Education Hours:
Check the boxes below to select which of the following items are displayed on the MSNHA web site:
Email     Phone     Web Address
Program Coordinator:
*First Name
*Last Name
*Phone	Ext.:
*Is this program open to all licensed administrators? Yes     No
For approval, please specify where this program falls within the Domains of Practice by checking all that apply. Ancillary Services Care Setting Financial Management Human Resources Leadership Organizational Strategy Quality of Care Quality of Life Regulatory Compliance Risk Management Upload a document that contains all documents showing the description of the program and the program agenda. UPON COMPLETION OF THE PROGRAM, THE SPONSOR IS RESPONSIBLE FOR SUBMITTING A TYPED LIST OF PARTICIPANTS (IN ALPHABETICAL ORDER), ALONG WITH A PHOTOCOPY OF THE SIGN-IN SHEET(S), TO THE BOARD OFFICE When you have completed the information above, click Continue to enter the dates and locations on the next screen.
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