INFORMATION/INSTRUCTIONS: PLEASE READ CAREFULLY

Processing may take up to 30 days. Please plan accordingly.

CPPN will not advertise nor take registrations for any educational activity until planning form is completely processed.

COURSE REQUIREMENTS:

When planning form is completed, submit to cppn@health.ucdavis.edu

All of the following components are required to be submitted to start processing: (1) Social Work CE Course Planning Form, (2) course agenda, (3) all course materials (including presentations, handouts, and pilot testing and posttests if used), (4) course bibliography/reference list (included in this form), (5) all promotional materials, (6) all resumes/CVs and proof of licensure for instructors/presenters and planning committee members, and (7) all biographical/conflict of interest forms for instructors/presenters and planning committee members, including a brief bio for promotional materials.

CPPN will not publish nor take registration for a course until the planning form has been endorsed.

Continuing Education (CE) contact hours are provided for a three-year period. To offer the same course after that date, the coordinator must submit a new CE Course Planning Form.

COURSE CONTENT

If you wish for your course to be considered for Association of Social Work Boards’ (ASWB) Approved Continuing Education (ACE) program credit, you will need to meet the following criteria:

Social Work Consultant must be involved in the planning, implementation, and monitoring of social work continuing education to ensure ASWB ACE standards are met. Please contact cppn@health.ucdavis.edu to discuss. ASWB ACE credit cannot be awarded if Social Work Consultant is not involved in course planning and/or does not assess course as meeting standards.

All ASWB ACE required information must be included in planning form. Review ASWB ACE Instructions Sheet for full details.

The content of all CE courses must be relevant to evidence-based social work practice and reflect current peer-reviewed research, best practices, and the needs and scope of licensed social workers.

Course content should: (1) help social workers better serve the public and support ongoing professional competence; (2) be understood as building on a degree in social work for someone currently practicing as a licensed social worker; and (3) be credible (i.e., empirical, peer reviewed, follows established research procedures) or address legal, ethical, or regulatory professional standards.

Course offerings must be at least 60 minutes (1 hour) in length. The first 60 minutes must be uninterrupted instruction.

Credit cannot be offered for completing part of a course.

ASWB ACE Requirement on Cultural Awareness and Diversity: CE content must promote cultural awareness and understanding of diversity such as defined in the NASW Standards and Indicators for Cultural Competence in Social Work Practice, 2015. CE for professional practice and licensing should advance cultural competence within the profession, preparing social workers for culturally competent practice across the full spectrum of social work practice roles—direct practice, supervision, administration, policy, education, and research.

Cultural competence requires self-awareness, cultural humility, and the commitment to understanding and embracing culture as central to effective practice.

Diversity, more than race and ethnicity, includes the sociocultural experiences of people inclusive of, but not limited to, national origin, color, social class, religious and spiritual beliefs, immigration status, sexual orientation, gender identity or expression, age, marital status, and physical or mental disabilities.

Acceptable course content areas include topics that clearly fall within the scope of practice for social workers and are directly applicable and relevant to social work practice, relating clearly to one or more of the following social work educational areas. Refer to ASWB ACE Instructions Sheet.

Questionable course content areas include touch therapy (e.g., Reiki), insurance billing, compassion fatigue, yoga, and mindfulness.

Unacceptable course content areas include, but are not limited to:

Exam prep, self-help, self-development, personal growth/enrichment, general leadership or management, technology enhancement, staff orientation, company-specific policies or procedures, topics that are primarily procedural or oriented towards business practices, CPR, infection control, interpreter training, commercial content, topics outside the social worker scope of practice, coaching (courses that discuss coaching in general and do not require the participant to be a licensed mental health or health care professional), or any political and religious content restriction.

Note: training that applies to leaders in any field, even when helpful to social workers in management roles, is not considered acceptable for social work CE credit unless the course includes learning objectives specific to social workers.

TWO LEVELS OF CPPN SUPPORT:

CPPN-based courses, which means that the class is on the CPPN website and open to all (internal and/or external) who wish to attend. CPPN handles the registration, evaluation, printing of course materials (if received 10 days prior to the class), questions concerning, etc. CPPN personnel will be on hand to open and close the class, supply AV equipment, and support as needed.

Note: For all CPPN-based courses, there is a base deposit of $25 for UCDH employees and a fee per hour charged for non-employees. Registration cost varies depending on length, catering needs, duplication, honorariums, etc. This is determined by CPPN.

Unit-based courses, which means opened to only a select group/unit of staff only to attend, and no pre-registration nor deposit required. CPPN supplies in advance blank rosters and evaluation forms only.

COURSE FEES

Course fees are dependent on multiple factors and are thus at the discretion of CPPN.

All CPPN courses have a minimum of a $25 deposit for UCDH employees.

If non-UCDH employee, there is a fee for all contact hours awarded.

Return entire form and direct questions to:

cppn@health.ucdavis.edu

Title of Activity: Click here to enter text.
TO BE COMPLETED BY CPPN
Date received: Consent to provide course date: Renewal date: (3 years from consent to provide course) Click here to enter a date. Click here to enter a date. Click here to enter a date.
Course Code: Click here to enter text.
Contact Hours: Click here to enter text.
Type: ☐ CPPN Course ☐ Unit-Based Course
Planning form reviewed and meets regulatory criteria. CPPN Consent to provide course: Click here to enter text.
Planning form reviewed and course meets Association of Social Work Board ACE regulatory criteria. Social Work Consultant Consent to provide course: Click here to enter text.
Social Work Consultant / Planner: Click here to enter text.
CPPN Coordinator: Click here to enter text.

ASWB ACE Planner Notes:

CPPN Planner and Analyst Notes:

Course Code: (entered by CPPN)
Submitter’s Contact Information
Submitted By (Name, Degree, Credentials, Title): Click here to enter text.
Department: Click here to enter text.
Telephone: Click here to enter text.
UCDH email address: Click here to enter text.
Social Work Consultant / Planner: Click here to enter text.
CPPN Course Coordinator: Click here to enter text.
Location: Click here to enter text.
Maximum # participants for Activity: Click here to enter number.
Activity Type: (Choose one that applies; must list enduring material creation/review date on promotional materials) ☐ In-person course: Initial Date of live activity: Click here to enter a date. Additional Dates: Click here to enter text. ☐ Distance learning, synchronous (live webinar, teleconference, audio/video conference): Initial Date of live activity: Click here to enter a date. Additional Dates: Click here to enter a date. ☐ Distance learning, asynchronous (self-paced, home study, recorded webinar, recorded audio/video conference): Start date of enduring material: Click here to enter a date. Review/expiration date of enduring material (maximum: 3 years after creation): Click here to enter a date. ☐ Hybrid/blended activity (two or more formats): Date of live portion of activity: Click here to enter a date. Date(s) of enduring materials (e.g., module or prework): Click here to enter a date. Review/expiration date of enduring material (maximum: 3 years after creation): Click here to enter a date.
Course Start Time: Click here to enter text.
Course End Time: Click here to enter text.
Brief Course Description for website posting/promotional materials. Include attendance requirements, educational level, any prerequisites or assignments, need to wear scrubs/work attire, etc.: Click or tap here to enter text.
Content Level:
Target audience is Licensed Clinical Social Workers. Include additional target audience, if any: Click or tap here to enter text. Course content is focused on the following level: ☐ Beginning (introduces learners to a content area and involve learning and comprehending content ☐ Intermediate (provides information that builds on knowledge, focuses on skill-building or adding knowledge) ☐ Advanced (addresses complexities involved in the work, involves synthesizing or evaluating material)
Communication Contact Method: (to be included on promotional material)
☐ Allow participants to contact submitter/planner via email regarding subject matter ☐ Alternative contact method and time - Describe: Click here to enter text.
Category of Social Work CE offering:
☐ Clinical ☐ Ethics and/or Law ☐ Cultural competency ☐ Suicide risk assessment & intervention ☐ Other - Describe: Click here to enter text.
Identified Need:
Identified Need/Gap: (What learning need are you fulfilling?) Click or tap here to enter text. Evidence to validate the identified need (check all methods/types of data that apply): ☐ Survey data or input from stakeholders, target audience members, subject matter experts, or similar ☐ Evidence from quality studies and/or performance improvement activities to identify opportunities for improvement ☐ Evaluation data from previous education activities ☐ Trends in literature, law, and health care ☐ Direct observation ☐ Other—Describe: Click here to enter text.
Registration opened to: ☐ Open to all who match target audience ☐ UC Davis Employee only ☐Unit (Group), specify:
Level of CPPN support requested: Review “Two Levels of CPPN Support” on page 2 of this form ☐ CPPN-based course ☐ Unit-based course
Learning Objectives: (write on Educational Planning Table of this form; to be included on promotional material)
☐ Social Work Consultant: Learning objectives meet ASWB ACE requirements (i.e., clear, concise, measurable, directly related to the social work profession). Review ASWB ACE Instruction Sheet, pp 3-4. Social Work Consultant Notes, if warranted: Click or tap here to enter text.
Instructor Qualifications:
☐ Social Work Consultant: Instructor qualifications meet ASWB ACE requirements (i.e., in good standing with professional regulatory board, has specialized training or extensive experience in subject, is proficient at using technology if delivering distance education, etc.). Review ASWB ACE Instruction Sheet, p 4. Social Work Consultant Notes, if warranted: Click or tap here to enter text.

Learner Engagement Strategies Select from list the learner engagement strategies that will be employed:
☐ Discussion ☐ Question/Answer or Socratic Questioning ☐ Storytelling/Narrative ☐ Reflection ☐ Demonstration/Return Demonstration ☐ Group Work ☐ Case Study Analysis	☐ Gamification ☐ Role Play/Simulation ☐ Problem-based Learning ☐ Self-Learning Module ☐ Blended Learning/Flipped Classroom ☐ Concept mapping ☐ Other – Describe: Click or tap here to enter text.
Instructional Materials:
☐ Social Work Consultant: Instructional materials reviewed and meet ASWB ACE requirements (i.e., enhance participant understanding, appropriate to learning level, professional, carefully reviewed and modified if initially developed for non-social workers, do not violate copyright or licensing rights, etc.). Review ASWB ACE Instruction Sheet, pp 4-5. Social Work Consultant Notes, if warranted: Click or tap here to enter text.
Promotion of Cultural Awareness and Understanding of Diversity:
☐ Social Work Consultant: Course content promotes cultural awareness and understanding of diversity. Review ASWB ACE Instructions Sheet, p. 1. Social Work Consultant Notes, if warranted: Click or tap here to enter text.
Criteria for Awarding Contact Hours: (to be included on promotional material)
Criteria for awarding contact hours for live and enduring material activities include: ☒ No contact hours awarded if late to activity as described in course description; must attend full sessions (required) ☒ Submission of evaluation form by all learners wanting CE credit (required for all courses) ☐ Submission of attendance attestation by all learners wanting CE credit (required for all in-person courses) ☐ Successful completion of a posttest (required for distance learning, optional for non-distance learning) ☐ Successful completion of required eLearning (i.e., Pre-Study) ☐ Other - Describe: Click here to enter text.
Distance Learning Courses, Required Information: (to be included on promotional material)
☐ Description of specific delivery method for website (beyond “online”, should state if participants are reading course material, watching a recorded video, attending a live webinar, etc.) - Describe: Click here to enter text. ☐ System requirements - Describe: Click here to enter text. ☐ Date recorded or created, if asynchronous (self-paced): Click here to enter a date. Course interactivity type: ☐ Interactive (must use posttest unless live with interactive questions and participation monitoring) ☐ Noninteractive (must use posttest) ☐ Interactive, synchronous (live) course will use interactive questions/polling with participation monitored (in place of posttest) ☐ Posttest used (all distance learning courses except interactive, live courses with discussion and participation monitoring) – information below is required: ☐ Posttest requirements (passing score and retest policy) - Describe: Click here to enter text. ☐ Description of how posttest and evaluation are given to participants and submitted - Describe: Click here to enter text. ☐ Credit desired for completing posttest (must pilot test course and posttest per ASWB requirements if credit offered for posttest). ☐ Course and posttest were pilot tested. Average amount of time to complete education portion and posttest (provide separate documentation of pilot test.: Click or tap here to enter text. ☐ Social Work Consultant: Posttest provided with materials, reviewed, and meets ASWB ACE requirements. Notes: Click or tap here to enter text.
Conferences:
☐ Concurrent conference ☐ Nonconcurrent conference ☐ Full attendance to entire conference is required The following sessions are planned for ACE credit: Click or tap here to enter text.
Reference List/Bibliography: (to be provided to participants on General Information Sheet near end of this form)
☐ Content is based on best available current evidence and best practices to foster achievement of desired outcomes. ☐ At least 50% or five of the references, whichever is less, must reflect research published within the last five years. ☐ The course bibliography includes all source material used, consulted, referenced, or quoted for each session. ☐ The course bibliography was updated to demonstrate validity and currency – Describe: Click here to enter text. ☐ The bibliography is listed in APA format, will be provided to participants, and is available upon request. ☐ Social Work Consultant: Bibliography reviewed and meets ASWB ACE requirements. Social Work Consultant Notes, if warranted: Click or tap here to enter text.

List of Individuals in a Position to Control Content
Complete the table below for each person in a position to control content of the educational activity (e.g., social work consultant, instructors/presenters). For each individual, include name, credentials, educational degree(s), and role in the activity. Each person must submit their (1) resume/CV, (2) proof of their license, (3) a bio to display on promotional materials, and (4) a complete Biographical and Conflict of Interest Form that validates their expertise to fulfill their respective role and includes a bio for display on promotional materials (annually for ongoing courses). Each instructor/presenter must be a member of a licensed profession, in good standing with their regulatory board, and have professional qualifications listed below. Instructors delivering distance learning must be available for participant communication and be proficient in using technology to communicate content effectively. The Social Work Consultant must be identified and involved in planning the course, including assessing educational needs, reviewing or developing objectives, administering and monitoring the course, ensuring cultural awareness and diversity is infused into content, resolving grievances, and evaluation. Every person must complete a Biographical and Conflict of Interest (COI) form, including a bio for each instructor to display on web/promotional materials.

Name of individual and credentials (i.e., John Smith, PhD, LCSW)	Individual’s role in activity (Social Work Consultant, Planning Committee, Instructor)	Required: In good standing with professional regulatory board (Yes, No)	Required: Is either (1) faculty member of accredited school of social work, (2) has specialized graduate or postgraduate training in subject being taught, or (3) has extensive experience including no less than five years of practical application or research in subject being taught (i.e., faculty, specialized training, experience)	Required: Member of licensed profession (list profession)	If potential conflict of interest: Name of commercial interest	If potential conflict of interest: Nature of relationship to the commercial interest (i.e., speaker bureau, stockholder, CEO, etc.)	COI form completed

(Add rows as needed)

Educational Planning Table

Content (Topics)	Learning Objectives	Time Frame	Instructor	Learning Strategies
Provide a general outline of the content/topic presented with main points for each topic. Acceptable content areas include topics that clearly fall within the social work scope of practice and are directly applicable and relevant to social work practice, relating clearly to social work educational areas. Refer to ASWB ACE Instructions Sheet for details. Include reference/resources used to develop content (may be as additional reference sheet)	(included on web posting) Must be clear and concise written statements defining the knowledge, skills, and abilities a learner should be able to demonstrate following the learning experience. Learning objectives originally written for non-social workers must be revised to include social workers/profession. Use Bloom’s Taxonomy (i.e., describe, discuss, apply, analyze, evaluate, etc.). Do not use verbs that cannot be demonstrated (i.e., know, understand, learn).	in minutes Must match provided course agenda Note: the first 60 minutes must be uninterrupted	List instructor(s) name, credentials, degrees for each topic/content area. Each instructor must submit a COI/Bio form Instructor Bio(s) to be included on web posting	List the learning strategies for each topic or content area. Include learner engagement strategies.

(add rows as needed)

Reference List/Bibliography:

Content must be based on the best available current evidence and best practices to foster achievement of desired outcomes. At least 50% or five of the references, whichever is less, must reflect research published within the last five years. The course bibliography must also (1) include all source material used, consulted, referenced, or quoted for each session and (2) be updated regularly to demonstrate validity and currency. Current APA format must be used.

This bibliography must be provided to participants (see Course General Information Sheet near end of this form to provide list).

All the following should be sent to CPPN at hs-cppn@ucdavis.edu for attachment to final course document.

Attachment 1	CE Planning Form (this form)
Attachment 2	Agenda (for each course date if changes occur)
Attachment 3	All Biographical/Conflict of Interest forms, CVs/resumes, proof of licensure, and bio statements for each instructor
Attachment 4	Course Materials: all presentations and handouts (with repeated classes, note version if changed)
Attachment 5	Course Bibliography/Reference List (individual lists for each session in a conference)
Attachment 6	Course Posttests, if applicable
Attachment 7	Course Pilot Test information, if applicable
Attachment 8	Course Advertisements/Promotional Materials (save the dates/course flyers/description for web page)
Attachment 9	Commercial Support Agreement with signatures and date, if applicable

Attachments to be supplied by CPPN

Attachment 1	Certificate of completion documentation
Attachment 2	Course Roster forms
Attachment 3	Course Evaluation forms
Attachment 4	Course Attestation forms, if applicable
Attachment 5	Summative evaluation
Attachment 6	Evidence of required information provided to learners: Materials associated with the activity (marketing materials, advertising, agendas, and certificates of completion) must clearly indicate the provider awarding contact hours and responsible for adherence to ASWB ACE criteria. This includes, but is not limited to: Accreditation statement of provider awarding contact hours Criteria for awarding contact hours Presence or absence of conflicts of interest for all individuals in a position to control content (e.g., the planning committee, instructors/presenters, faculty, authors, and content reviewers) Commercial support (if applicable) Expiration date (enduring materials)

This form is required to be given to attendees prior to the start of any educational activity

Requirements for completion of this program

For an in-person event, participant must sign in on official roster, be present for the entire course, and complete an evaluation and attestation of attendance. Additionally for a conference, participants must complete evaluations for each activity or session as well as an evaluation for the overall conference.

For a distance learning course, the participant must complete the entire course, a course evaluation, and a posttest if the course is noninteractive. The evaluation and posttest, if used, is provided and submitted electronically during the course.

Participant must sign attestation of participation in activity for all live, synchronous activities no later than the end of the day that the activity was offered (for a multi-day course, attestation must be turned in each day).

C.E. credit will not be awarded for this program session if the participant does not attend the course in full.

Posttest requirement if used (passing score and retest policy): Click or tap here to enter text.

Specific requirements for individual course: Click or tap here to enter text.

Conflict of interest

Conflict of interest can exist when an individual has an opportunity to affect continuing education/ professional development content in relation to an ineligible company (previously termed commercial interest) in which they have a relevant financial relationship.

Unless indicated below, all planners and instructors/presenters associated with this program no relevant financial relationships with ineligible companies with relation to the content of this program.

Off label use

This educational activity does not include any unannounced information about off label use of a product for a purpose other than that for which it was approved by the Food and Drug Administration (FDA).

Potential Conflict of Interest Notification to Course Attendees (select one and describe as needed)

☐	There are no relevant financial relationships with ineligible companies (previously termed commercial interests) to disclose among planners, faculty, and everyone in control of content.

☐	Relevant financial relationships exist and are disclosed to learners below, including the names of individuals with relevant relationships, names of ineligible companies (previously termed commercial interests), the nature of relationships, and a statement that all relationships have been mitigated.

Click or tap here to enter text.

Bibliography

This educational activity used the following reference material:

Title of Activity: Click here to enter text.

Completed by CPPN	Reviewed by SW Consultant	Explanation of planning form requirements – please direct any questions to hs-cppn@ucdavis.edu Additional information on requirements found in ASWB ACE Instructions Sheet.
Title of Activity: Should be specific to content; if course is part of a series should be differentiated by day (i.e., Day 1, Day 2, Part 1, Part 2., Pediatric Critical Care Day 1).
Location, Maximum Number of Participants, Start/End Time: Should be specific. This is what will be posted on the website and learning management system for advertisement and communications.
Brief Course Description for website posting: This is what will be post on the website for course advertisement. If there are any prerequisites or attendance requirements, please state clearly. Additional content to be included on promotional materials: requirements for course completion, learning objectives, target audience, instructor bio(s), outline or agenda with specific times and breaks, and, for conferences, registration deadline. Distance learning courses must also include delivery method, interactivity type, date recorded or created (if asynchronous), and system and posttest requirements.
Audience: Who the course is targeted towards, and any restrictions on that audience (i.e., only social workers, only UC Davis employees, etc.). Indicate level of CPPN support requested.
Cultural awareness and understanding: Should be incorporated into course, as defined in the NASW Standards and Indicators for Cultural Competence in Social Work Practice.
Criteria for Awarding Contact Hours: List any beyond attending class in full and completing evaluation.
Pilot testing: Provide pilot testing data, if used.
Post testing: Provide posttest and requirements that meet ASWB ACE requirements.
Conflict of Interest: All persons in a position to control the content of the educational activity are required to complete the Biographical and Conflict of Interest Form. Planning forms will not be processed until all forms are completed.
Instructor qualifications: must meet ASWB ACE requirements (i.e., in good standing with professional regulatory board, has specialized training or extensive experience in subject, is proficient at using technology if delivering distance education, etc.). CV/resume, proof of licensure, bio, and COI form are completed and appropriate for ACE.
Educational Design: Content/Topics – Acceptable course content areas include topics that clearly fall within the social worker scope of practice and are directly applicable and relevant to social work practice, relating clearly to one or more of the social work educational areas, listed on the ASWB ACE Instructions sheet. Objectives – written as to what the learner should be able to do, not what the speaker is going to talk about. Must be clear and concise written statements defining the knowledge, skills, and abilities a learner should be able to demonstrate following the learning experience. Learning objectives originally written for non-social workers must be revised to include social workers/profession. Use Bloom’s Taxonomy to assist you with writing learning objectives (i.e., describe, discuss, apply, analyze, evaluate). “At the end of this session the learner will be able to…” Do NOT use verbs that cannot be demonstrated (i.e., know, understand, or learn); these are unacceptable objective verbs. If you need assistance with writing your objectives, contact: hs-cppn@ucdavis.edu Time Frame – amount of time in minutes to present topic (i.e., 60; not specific clock time 0800-0900). Specific times should be reflected in the class agenda, which aligns to Educational Planning Table. Instructor/Presenter – name, credentials, and title of person(s) presenting Learner Strategies – include how information going to be presented (i.e., demonstration, case study discussion, group brainstorming, etc.). Including learner engagement strategies is a best practice and will positively affect the activity and resulting knowledge, skills, practice change(s).
Agenda: Course agenda must be provided with Course Planning Form with outlined specific times and breaks. Agenda must match Educational Planning Table.
Instructional materials: must meet ASWB ACE requirements (i.e., enhance participant understanding, appropriate to learning level, professional, carefully reviewed and modified if initially developed for non-social workers, do not violate copyright or licensing rights, etc.).
Reference List/Bibliography: Content must be based on the best available current evidence and best practices to foster achievement of desired outcomes. At least 50% or five of the references, whichever is less, must reflect research published within the last five years. The course bibliography must also (1) include all source material used, consulted, referenced, or quoted for each session and (2) be updated regularly to demonstrate validity and currency. Current APA format must be used. If the bibliography includes writings the course instructor authored, it must also include relevant, current references from writings of other authors. Bibliography must be provided to participants (use General Information Sheet of this form to provide).