CE Individual Application Form

To be considered for course approval, please follow all instructions, complete all of the required fields, and allow 30 days for approval. Individuals can submit a course for approval any time after course completion.

Click here for required materials to include with application.

CE Individual Application

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone
Email
Enter Email Confirm Email
State how the course you submitted relates to your personal current or future practice of PT.
Course Information
Conference/Symposium/Course Title*
Primary Instructor(s):
Are there other instructors?
If "Yes", please list other instructors on the required course schedule.
- No
- Yes
Is this course is being submitted to meet the Indiana CE requirements for one of the following?
Check all that apply
- Ethics (1 or more contact hours)
- Indiana Jurisprudence (1 or more contact hours)
Course Type(s):
Check all that apply
- Synchronous Distance Learning (liv e webinars or streaming, etc.)
- Asynchronous Distance Learning (pre-recorded videos, discussion boards, home study, etc.)
- On-site – List city and state of course attendance :
Date(s), or first available date(s) if multiple offerings:

The 12-month approval period will start with this date. If no date is offered or if the applicant writes, “to be determined,” or similar, the date of submission will be used as the start of the 12-month period.

Note: For one day courses, enter the course date in the From date box.
From:*
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Sponsor Section
Please provide as much information as you can. A lack of information may delay or affect approval.
Course Provider
Name
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone
Email
Website
Application Fees and Contact Hours
All fees are non-refundable. Enter the proposed number of contact hours using the rubric in the instructions below.
Proposed Number of Contact Hours (where 60 minutes = 1 contact hour)*
Are you an APTA member?
- No – Please pay $40
- Yes – Please pay $15
Required Attachments
Please upload one combined PDF document containing all of the items listed in the "Required Materials" section below, in sequence after the application page. Please note that failure to combine all items into one PDF may result in a delayed or rejected application. Incomplete applications are closed after 30 days and will require resubmission. Detailed instructions for each item below can be found below in the "Instructions for Individual Application Form".
Upload File*
Drop files here or

Accepted file types: pdf, Max. file size: 32 MB, Max. files: 10.
Phone
This field is for validation purposes and should be left unchanged.

Instructions for Individual Application Form

Detailed course description: Detailed explanation of course and how this course directly relates to physical therapy practice, including how participation in the course should improve the clinical outcomes of the participants.
Specific, measureable learning objectives, related to the course description (at least 5, with at least one that refers specifically to a review of current evidence): Clearly written outcome statements denoting the attitudes, knowledge, and/or skills that participants should attain by the conclusion of the course. These should directly tie back to the course description. Due to the importance of evidence-based practice in healthcare professions, one of these must refer to a review of current evidence. There should be a minimum of 3 objectives for a 1.0-4.0 contact hours course, or 5 for a course with more than 4.0 contact hours.
Presenter(s)’ credentials/qualifications to teach the specific course material (full CVs required for primary presenters; bio-sketch CVs accepted for other presenters): Full CVs (often several pages) are required to determine the qualifications of the primary course instructor(s). Bio-sketch CVs (2-3 pages) are required for every other type of presenter, instructor, lab assistant, or another other such person involved with the educational process. These CVs should specifically demonstrate why the particular presenter is qualified to teach this particular course.
References, including at least 5 works within the past 10 years, of which at least 2 works must be within the last 5 years: References should follow a professional formatting style, such as AMA or APA style, so that all necessary information to verify the accuracy of the reference is possible, including page numbers. For electronic resources, the same formatting style should apply; consumer websites are not acceptable as references. There should be a minimum of 3 references in the last 10 years (with 1 in last 5 years) for a 1.0-4.0 contact hours course, or 5 in the last 10 years (with 2 in last 5 years) for a course with more than 4.0 contact hours. Recent references are important for providing participants with current knowledge.
Detailed course agenda/schedule, justifying the requested contact hours (or for asynchronous course, a detailed explanation of instructional methods – discussion boards, videos, tests, documents to read, etc. – with expected time to complete each learning module): contact hours will not be awarded for activities that do not relate to the educational experience; this includes breaks, meals, registration, and course/instructor evaluation. These items should still appear on course agendas for clarity. If estimations are used for time to complete online or home study activities, a detailed explanation of how this time schedule was determined should be attached.
Sample course and instructor evaluation form: As feedback from the participant is important to assess whether the planned course objectives were met, a sample feedback form is required.
Copy of course completion certificate: Required items on the completion certificate include the course title, number of contact hours, course sponsor, course instructor, participant name, course dates of attendance or completion, course location (if applicable), and signature of the instructor or sponsor designee.
Method of assessing student learning: Explain in detail how the instructor determined that learning objectives were met. Possible options include but are not limited to Q&A session, post-test, and observation of lab practice. Provide a copy of any post-test or other items to substantiate this item. For asynchronous courses, a copy of the post-test must be submitted.

If you do not have one or more of these items, you should be able to contact the course instructor or sponsor to request required items. Most instructors and sponsors are willing to provide these items to assist with the contact hours approval process. Many of these items can be found in the course brochure and handouts provided at the course. It is the responsibility of the applicant to provide this information. Course reviewers will not seek this information from the instructor or sponsor on behalf of the applicant.

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CE Individual Application Form

To be considered for course approval, please follow all instructions, complete all of the required fields, and allow 30 days for approval. Individuals can submit a course for approval any time after course completion.