BABIES CAN’T WAIT CONTINUING EDUCATION DOCUMENTATION FORM

This form is to be used by BCW personnel who need to document educational activities for Continuing Education (CE) credit through BCW or to seek pre-approval of Individualized Learning Activities (ILA). All persons should complete Section I, then complete Section II, III, or IV as applicable.
SECTION I. DEMOGRAPHIC DATA:
Name:_____________________________________________________________
Agency/Position Title: ________________________________Length of time in Position:_______________       Address:_________________________________________City: _________________Zip code:________  Telephone:(_____)_____________________ Email: _____________________ Health District: _________________
Date Submitted to Project SCEIs _____/______/____

SECTION II.   ____ FOR PRE-APPROVAL OF A PROGRAM YOU WANT TO ATTEND (see items 1, 2, & 4 below)    OR                                       ____ FOR DOCUMENTATION OF A PROGRAM YOU HAVE ALREADY ATTENDED
Please note: This form must be post marked/fax dated to Project SCEIs no later than forty-five calendar days FOLLOWING the completion date of the conference/training/workshop.
Contact Hours :_________                 Category:   _____ Children and families   (Check One)
                                                                  _____  Children with disabilities and their families
Please submit the following:
1.This form with Section I & II completed.
2. The agenda and/or the program brochure from the program you attended or want to attend.
3. Your certificate of attendance for the program, if it has occurred.
4. If the program you attended does not have a birth to age 8 focus, but addresses a BCW served disability category, please submit a statement regarding its pertinence to your current position.

SECTION III. PRE-APPROVAL OF INDIVIDUALIZED LEARNING ACTIVITY (ILA)
Please note: ILA must be submitted for pre-approval thirty calendar days IN ADVANCE of the start date of the ILA.
Contact Hours :_________                     Category:  _____ Children and families (Check One)
                                                                    _____ Children with disabilities and their families
(attach additional pages if necessary)
1. Objectives of the Individual Learning Activity:___________________________________________ _________________________________________________________________________________
2. Description of activities to achieve objectives:____________________________________________
_________________________________________________________________________________
3. Name(s) and credential(s) of person(s) who will be your facilitator/mentor for this activity:___________
_______________________________________________________________________________
4. Location of learning activity (if applicable): ___________________________________________
________________________________        ______/_______/_______             ______/_______/____
Supervisor’s signature                                            Today’s   Date                                        ILA Start Date

SECTION IV. DOCUMENTATION OF INDIVIDUALIZED LEARNING ACTIVITIES
Please note: This form must be resubmitted no later than forty-five calendar days FOLLOWING completion date of the ILA.
Upon completion of learning activity, have your supervisor write a verification (on letterhead) addressing items 1-4 above, then submit this approved form and the verification.

ALONG WITH REQUESTED DOCUMENTATION, MAIL/FAX TO:
Project SCEIs CE Committee; EPSE Department; Georgia State University;
P.O. Box 3979; Atlanta, GA 30302-3979
Phone: 404-413-8330 Fax: 404-413-8043

For office use only:

SECTION V. PROJECT SCEIs CONFIRMATION                                                 Date reviewed:______________
ID Number:_______________________
Approved: ________                     Hours:_______ Children and families
                                                                        _______ Children with disabilities and their families
Disapproved: ________ Reason:_________________________________________________________
_______________________________________________________________

Individuals who wish to document BCW Continuing Education Hours for a conference/training/ workshop or Individualized Learning Activity should use the
CONTINUING EDUCATION DOCUMENTATION FORM.
If you are unsure if the program you plan to attend will be approved, you may obtain pre-approval (though not required) by sending the program agenda and/or brochure (before attending) to Project SCEIs.   For documentation, the program MUST meet the following requirements in order to be accepted:
Documentation must be postmarked/fax dated to Project SCEIs no more than forty-five calendar days following completion of the conference/training/workshop or Individualized Learning Activity date. NO exceptions!!
The focus of the conference/workshop/training is on:
A. Children, birth to age 8.
B. Families of young children, birth to age 8.
C. A particular disability covered under Georgia’s BCW Program.
    For this category, the requesting individual must submit a statement of justification explaining the  pertinence of the training to one’s present position.

Individualized Learning Activities MUST be pre-approved no less than thirty calendar days prior to the start date of the activity and documented following the process stated above.

Continuing Education hours will be determined according to contact hours of the program. One Contact hour equals one hour of instructional time.

If you have any questions, please contact Emily at the Project SCEIS offices (404-413-8330; sceirem@langate.gsu.edu ).