Continuing Education Form
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Transcript of Continuing Education Form
104 | JAVA | Vol 16 No 2 | 2011
HOW TO EARN CONTINUING EDUCATION CREDIT
1. Read the continuing education articles (also available online).2. Complete the post-test and record your answers on this Continuing
Education Form. Note that you can use this printed form or you can access the form online (you will need to print the form out and complete the questions on the hard-copy print-out).
3. Complete the registration information and the course evaluation included on this Continuing Education Form.
4. Mail or fax the completed Continuing Education Form with your $10.00 fee - check or money order (payable to AVA) or credit card information (VISA, MasterCard, American Express, or Discover).
City ______________________________ State _____ Zip ___________
Phone: ( ____ ) ________________ Email ________________________
Social Security Number __ __ __ - __ __ - __ __ __ __
RN License Number and State of License:___________________________________________________________
Method of Payment ($10.00 fee required)❑ Money Order or ❑ Check made payable to AVA enclosed. ❑ Please bill my credit card ❑ VISA ❑ MasterCard❑ American Express ❑ Discover
Credit Card Number _____________________________Expiration Date ___________ Three-digit Security Code _____
Signature ___________________________________ Date ___________
Mail: Association for Vascular Access (AVA)5526 West 13400 South, Suite 229Herriman, UT 84096
Fax: 801-601-8012 (credit card payments only)
To earn 1 contact hour of continuing education, you must achieve a score of 70% (7 of 10 correct). If you do not pass the test, you may take it one additional time at no additional charge before the published deadline. Test results will be sent to you within 21 days of receipt of Continuing Education Form in our administrative office. A certificate indicating successful completion of this offering will bear the date your Continuing Education Form is received.
Continuing Education FormEvaluationDid the articles meet the course objectives? Yes ❑ No ❑
Is the home study format an effective way to present this material? Yes ❑ No ❑
Is the content relevant to your practice? Yes ❑ No ❑
Comments ___________________ __________________________________________________________
Suggestion for future topics ___________________________________
Length of time required to complete this program? ____________
Accreditation Provider approved by the California Board of Registered Nursing, Provider Number CEP12371 for one contact hour.
Please call 877-924-AVA1 or801-792-9079 if you haveany questions.
http://www.avainfo.org Submission must be postmarked by November 1, 2011.DOI: 10.2309/java.16-2-7