Continuing Education Form

of 1 /1

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). Name _____________________________________________________ Address ___________________________________________________ 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 229 Herriman, 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 Form Evaluation Did 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 or 801-792-9079 if you have any questions. http://www.avainfo.org Submission must be postmarked by November 1, 2011. DOI: 10.2309/java.16-2-7

Author
lamque
Category

Documents
view
213
download
0

Embed Size (px)

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).

Name _____________________________________________________

Address ___________________________________________________

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