Wyoming

Speech-Language-Hearing Association
Application to Co-Sponsor Continuing Education Activities

The Wyoming Speech-Language Pathology and Audiology Association (WSHA) will individually
administer co-sponsorship of CE activities that meet ASHA required guidelines. All events and topics
must conform to ASHA guidelines for professional or related content. Speaker must possess professional
qualifications. The focus of the activity must not be for the sale of a specific product. Please contact the
WSHA CE Administrator as soon as you begin planning your event so we can assist you with the
necessary ASHA requirements.

Instructions:
Respond to each of the questions below and attach required information. Course and Offering
Registration Form and required attachments must be received a minimum of 90 days prior to the event.
Shorter time frames are submitted to ASHA as exceptions and can be negotiated with the CE
Administrator. Detailed instructions and additional forms are available on the WSHA website
(www.wyomingspeechlanguagehearingassociation.org).

Contact Person:

Address:

Contact Phone:
Contact Email:

Contact relation to the organization/company offering the activity:

Organization/company offering CE activity:

Expected attendance:
Attendee cost for activity:

Location of the activity:

Beginning date of activity:
Ending date of activity:

Total CEUs offered:
Total hours offered:


(60 minutes or 1 contact hour = 0.1 CEU, time does not include breaks)
Course Title (not to exceed 60 characters):

Course Description (not to exceed 300 characters):

Subject Code (click on one check box):
1010 Fluency Disorders - Assess and Intervention
1020 Voice Disorders - Assess and Intervention
1030 Motor Disorders of Speech - Assess & Intervention
1040 Dysphagia - Assess and Intervention
2010 Speech Science
3010 Lang Disorders - Assess & Intervention
3030 Lang Disorders -Aphasia and Acquired
Neurogenic Disorders & Cognition
3040 Language Disorders - AAC
3050 Language Disorders - Articulation
4010 Language Science
5010 Audiology - Assessment
5020 Audiology - Habilitation/Rehabilitation
5030 Hearing Assistive Technology
5040 Industrial Audiology/Hearing Conservation
6010 Hearing Science
7010 Service Delivery assoc with Sp/Lang/Hearing
7015 Pre-professional Education Assoc with Sp/Lang/Hearing
7020 Education/Training issues in Sp/Lang/Hearing
7025 Regulatory Issues in Sp/Lang/Hearing
7030 Cultural and Linguistic Diversity in Education & Public Policy
7040 Psycho-social Issues in Assess & Intervention
7050 Leadership and Management in Profess Practice Setting
7060 Patient Safety and Prevention of Medical Errors
8010 Microcomputer and Technology
9010 Speech-Language Conferences with Multiple Sessions
9015 SLP Self Study or Journals
9020 Audiology Conferences w/ multi sessions
9025 Audiology Self Study or Journals
9030 Audiology and SLP Conferences with multiple sessions
9035 Audiology and SLP Self Study or Journal
9040 Review Courses for National Exam in SLP or Audiology

Content Code (click on one check box):
Basic Communication Processes
Professional


Related

Instructional Level (click on one check box):
Introductory assumes little or no familiarity with the area
Intermediate assumes general familiarity with the area
Advanced assumes thorough familiarity with the area
Various single level cannot be determined; multiple sessions

Type of Activity (click on one check box):
Workshop
2 Seminar
3 Conference
4 Forum
5 Symposium
6 In-service

7 Journal Group
8 Study Group
9 Grand Rounds
10 Teleconference
11 Videoconference/Satellite TV 12 Self Study: Video or Course
13 Self Study: Journal or newsletter
14 Convention
15 Short Course
16 Miniseminar
17 Technical Session
18 Poster Session
19 Roundtable Discussion
20 Traditional academic courses
22 Independent study
23 Web-based courses

List course offerings on Course Search on ASHA website?
Yes
No

If yes, please provide contact name and phone number or web address, etc.:

Course CEUs
Attach a copy of the time-ordered agenda that lists the activitys schedule by time periods including
content, instructional personnel, etc.

Can participants achieve the entire courses learning outcomes without full attendance? (Is partial
credit an option)?

No (continue to promotional materials section)
Yes (respond to the following)

How will course participants who do not attend the entire course demonstrate achievement of the
course learning outcomes? (check one):

The course has multiple sessions and each session has discrete learning outcomes that are
assessed at the end of each session.
The course is a series of sessions. Participants must attend a minimum of sessions.
A passing score on an exam is the satisfactory completion requirement.
Participant will successfully demonstrate a skill as the satisfactory completion requirement.
Other (please describe):

Disclosures and Promotional Materials
The Wyoming Speech-Language Hearing Association requires that all individuals involved in developing
and delivering course content to be offered for ASHA CEUs disclose relevant financial and nonfinancial
relationship(s).

Sample disclosure statements can be found by clicking on the following link:
http://www.asha.org/CE/for-providers/admin/Sample-Disclosure-Statements/

Attach a copy of the disclosure form for all planners and presenters.
Attach a copy of the promotional materials including course advertisement, which includes the
following:

1. The ASHA CE Approved Provider Brand Block and CEU sentence (Contact the WSHA CE
Administrator for a copy of the ASHA CE Approved Provider Brand Block by emailing the WSHA
CE Administrator: djseabeck@gmail.com)
2. Instructional personnel disclosure(s)
3. Disclosure that the course is focused on a specific product or service and there will be no or
limited information about similar products or services (if applicable).
4. Disclosure of the names of organizations contributing financial and in-kind support (if
applicable).

Prior to the course, did you disclose that the course content was focused on a specific product or
service?
Yes
Not applicable

Prior to the beginning of the course, will you disclose financial and in-kind support given by other
organizations used to pay for all or part of the costs of the CE course?
Not applicable
Yes, disclosure is made in promotional materials for all instructional personnel.
Yes, disclosure will be made at the start of the course for all instructional personnel.

Course Design Needs Assessment Process (check all that apply):
Interviewed key individuals
Conducted focus group(s)
Surveyed sample population
Other (please describe):


Learning Outcomes
Describe the skills, knowledge and/or attitudes (learning outcomes) participants will be able to
demonstrate as a result of this activity. These must be measurable such as: participants will:
demonstrate or describe or identify, etc.

Attach courses learning outcomes

Assessment of Learning Process (check all that apply):
Performance demonstrations
Written report
Written examination
Oral report
Oral examination
Self-assessment
Question and answer session
Other (please describe):

Instructional Methodology (check all that apply):
Lecture
Small group activity
Video or audio presentation
Panel discussion
Demonstration of procedures
Observation of patients
Case study

Simulations
Other (please describe):


Planning and Instructional Personnel
It is important instructional personnel meet ASHA requirements. Visit the ASHA website for resources on
the following:
Evidence-Based Continuing Education Tutorial
Guidance on Infusing Evidence into CE Course Content

For additional assistance, please contact the WSHA CE Administrator:
Diana Seabeck 307-742-7956 djseabeck@gmail.com

Satisfactory Completion and Course Evaluation
How will you determine whether participants meet the courses satisfactory completion requirements
and are eligible to earn CEUs? (check all that apply):
Attendance
Attainment of learning outcomes

Fees
Attach a $325 ASHA processing fee to this form plus attachments:

Check enclosed payable to American Speech-Language-Hearing Association (ASHA)
Credit Card
Visa
Mastercard
Credit Card Number:
Expiration Date:


Authorized Signature:______________________________________________

Return the completed Continuing Education Activity Approval Worksheet, required attachments, and
fees by US mail to: WSHA CE Administrator:

Diana Seabeck
2533 Park Avenue
Laramie, WY 82070

OR by email with attached documents to djseabeck@gmail.com

Timeframe In accordance with ASHA timeframes, the above requested information must be received
by the WSHA CE Administrator at least 90 days prior to the event. Timeframe exceptions may be
negotiated with the administrator.