Cooperative Offering Application

Course Information

Will the type of learning experience be:

Group (Live Event)

Individual (e.g., recorded version of a live course or peer-reviewed, self-study)

Blended (i.e., courses that combine group and self-study experiences)ird Choice

Course Title

Course Details

Course Registration Contact Information: Name & Phone Number

Name

First Last

Phone

Description of Course

ASHA CEU Find

Please indicate if you want your event to be listed on ASHA’s CEU Find (in other words are you opening it up to others outside of your organization to attend)?

Yes

No

Subject Code

For a list of Subject Code Categories visit https://www.asha.org/CEUFind/Subject-Codes/

Content Code

Professional

Basic Communication Processes

Introductory

Intermediate

Advanced

Various

ASHA CEUs and Course Structure

ASHA CEU Amount Requested:

CEU calculation worksheet

Max. file size: 100 MB.

Will Partial Credit be Available?

Is the course designed to allow an individual to earn less than the course’s maximum ASHA CEUs?

Yes

No

Please provide the structure for this course

The course structure information (e.g., agenda with run time, an outline, syllabus, table of contents or some other document that provides details on how the course is structured) can be uploaded on the attachments page or can be included as part of your promotional materials.

Outline

Syllabus

Table of Contents

Time Ordered Agenda

Other

Other Course Structure

Disclosures

Does the course content focus on a specific product or service?

Yes, and course content disclosure is available in the promotional materials.

No

Did any other organization(s) provide financial or in-kind support?

Yes, and financial or in-kind support disclosure statement is available in the promotional materials

No

PROMOTIONAL MATERIALS

Please indicate the media channel that contains the primary promotional material.

Email

Flyer

Mailing

Website

Other

Other Promotional Materials

Promotional Materials - Attached Copy or Provide Website Link:

Max. file size: 100 MB.

Promotional Materials Website Link

Reminder: Primary promotional materials must include:

ASHA CE Approved Provider Brand Block

Course information (instruction level and ASHA CEU amount)

Instructional personnel disclosure statements:

Disclosure that the course is focused on a specific product or service and there will be no limited information about similar products or services, if applicable: and

Disclosure of the names of organizations contribution financial and in-kind support, if applicable.

If the course (event) will be offered more than once, please list the dates and city, state, and times for each offering. Please include this information in your promotional materials, even if it’s offered one time.

ASHA requires a financial disclosure statement and non-financial disclosure statement for each speaker and that information needs to be included in the promotional materials, as well as a time ordered agenda, course description, and learning objectives for each session that will be offered at the event.

Here are examples: Financial Disclosure Statement: John Doe is employed by ABC Speech Therapy and is receiving honorarium for his conference session.

Non-Financial Disclosure Statement: John Doe has no non-financial relationships to disclose.

Your request for CE submission to the American Speech-Language-Hearing Association (ASHA) must be submitted to the Nebraska Speech-Language-Hearing Association (NSLHA) at least 60 business days prior to your event, without exception.

Contact Name

First Last

Email

Phone

Company

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cooperative Offering Fee

Price:

Total

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Billing Address of Credit Card

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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