Approved Provider Status Application/Renewal

Contact Information

Provider/Organization Name:

Address Line 1:

Address Line 2:


City:	State:	ZIP Code:


Provider Contact Person:	Phone Number:	Extension:	Email:


Are you renewing your application for Approved Provider Status?	Yes	No

Qualifications of Instructor(s)

Describe the criteria for selection of instructors for your programs.

Program Content

List the various areas of content your programs provide below. As per N.D. Admin. Code, Board-approved continuing education course content must relate to: theories and concepts of human behavior and the social environment, social work knowledge and skills, social work research or practice evaluation, social work ethics, or cross disciplinary courses directly relevant to social work practice or specialty.

Licensees are required to earn 2 contact hours in social work ethics per 2-year licensure period. No more than 10 contact hours may be earned via self-study or distance learning methods.

List the various areas of content your programs provide.

Evaluation

Identify the methods of evaluation that will be used to determine behavioral objectives have been met by the participants.

Attendance

Explain procedures for documenting participation; e.g. an attendance roster, sign-in log, etc.

Attendance Reporting

You will be responsible for issuing certificates of completion to all attendees stating the name and license number; also include on the certificate the title of the training, date of training, NDBSWE issued program approval number, and how many hours the attendee earned. The NDBSWE recommends you keep copies of the certificates or an attendance roster on file for 4 years. Failure to do so may result in the loss of approved provider status.

By checking this box, I acknowledge that I read and understand the information above.

Attachments

Certification


	By checking this box, I certify that:
	I hereby apply for Approved Provider status for continuing education. I hereby attest that I have reviewed the guidelines and criteria regarding continuing education and agree to present programs that meet the North Dakota Board of Social Work Examiner's criteria governing continuing education for social workers.

Approved Provider Status Application/Renewal

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