Tennessee Physical Therapy Association

PROVIDER APPLICATION FOR APPROVAL OF CONTINUING EDUCATION COURSES
(Please provide 3 copies with attachments)

 
Provider Information
Provider Name
Contact Person
Mailing Address
City State Zipcode
Telephone Fax
E-mail Address
Co-Sponsor Name (if applicable)
Mailing Address
City State Zipcode
Telephone Fax
Email Address

Course Information
Course Title
Check the topic area(s) that applies to this course

Administration
Acute Care/Hospital Clinical Practice
Aquatics
Cardiopulmonary
Clinical Electrophysiology
Education
Ethics/Professional Responsibility
Geriatrics
Hand Rehabilitation
Health Policy, Legislation, & Regulation
Home Health
Industrial Rehabilitation

Manual Therapy
Neurology
Oncology
Orthopedics
Pain Management
Pediatrics
Research
Sports
Women’s Health
Wound Care
Other

Type of Course

Location of Course
City State    

Date(s)
   
(Specify dates for which you are requesting approval.)

Target Audience

Instructional Level
- Participants have little information within the content area so that the focus is a general orientation and increased awareness.

Proposed number of contact hours
(Sixty (60) minutes of time actually spent in the educational portion of the course equals one contact hour. Credit is not given for registration, meals, or breaks. TPTA will award the number of CEUs based on the contact hours.)

Course content and schedule (Outline course schedule by time and a breakdown of the agenda)

Course Objectives

Instructional Methods

Instructor(s)

Instructor Qualifications

Method used to assess a participant's attainment of the course objectives

Participants’ evaluation of course (Describe how participants evaluate the course and instructor(s).)
(Send a sample evaluation form.)

Record Keeping Information
(Continuing education course providers are required to maintain records of participant attendance and course evaluation forms for three years.)
How/where are records maintained?
Who is responsible for maintaining participant records?
How long are records maintained?
Individuals authorized to sign letter or certificate of completion
(Send a sample of letter or certificate of completion)
Name
Name
Name

Fee Payment
Provider Fee*
$85.00
  
$135.00
  
$210.00
  
   
*The application fee payment is made on the basis of the proposed number of contact hours. If a different number of contact hours are actually approved, the fee will be adjusted accordingly.
*If the course is not approved, the fee less $50.00 is refundable.

Payment Method Check No.      Money Order

Payment by check or money order payable to the Tennessee Physical Therapy Association MUST follow application. Purchase orders are not accepted. The application will not be processed until payment is received.

I certify that the information provided in this application is true.
I agree to adhere to the “Policies on Approval of Continuing Education Courses” established by the Tennessee Physical Therapy Association.
Name Date
Title

Mail (3 copies) of the application form, fee payment, and all attachments to:

Tennessee Physical Therapy Association
Attn: CEU Approval
4205 Hillsboro Road, Suite 317
Nashville, TN 37215

If you have any questions, contact the TPTA office at 615-269-5312.