ASHA CEU Participant Form
ASHA CEU Participant Form American Speech-Language-Hearing Association Continuing Education Registry Provider Code
Course Number
Completion Date
Submit this form to the Provider at the end of the course if you wish to earn and maintain ASHA CEUs through the ASHA CE Registry (annual fee required). If not an ASHA member or CCC holder, you must be licensed or credentialed to practice speech-language pathology (SLP) or audiology or preparing to practice to earn ASHA CEUs.
Name ____________________________________________
Licensed: _______________________________________________________
Address __________________________________________
(State and License #)
City ________________________________ State _______
Certified: _______________________________________________________ (State/Organization and #)
Clinical Fellow: __________________________________________________ (Supervisor name and her/his ASHA account number)
Zip _______________ Country ______________________ Daytime Phone (_____)______________________________
Enrolled in a graduate program in SLP or audiology: _______________________________________
(Include Area Code)
E-mail Address ____________________________________
(University name and expected graduation date) Please enter your last name (as it appears on your ASHA id card) below. Enter the letters in the spaces provided in the 1st row and fill the entire box that corresponds to the letter in each column.
ASHA Account Number You must provide your ASHA Account Number.
Last Name (Only)
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
J
J
J
J
J
J
J
J
J
J
J
J
J
J
J
J
J
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
V
V
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Y Z
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
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1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
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3
3
3
3
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7
7
7
7
7
8
8
8
8
8
8
8
8
9
9
9
9
9
9
9
9
0
0
0
0
0
0
0
0
To update your address or phone number, or to obtain your ASHA Account Number call ACTION CENTER at 1-800-498-2071 between 8:30am and 5:00pm. E.T.
Provider Use Only Complete only for those participants receiving less than the maximum number of ASHA CEUs (i.e., partial credit). Please fill in leading zeros followed by the number of ASHA CEUs. For example, to indicate a participant earned .55 ASHA CEU's (that is, 5 1/2 hours) write 0055.
1 2 3 4 5 6 7 8 9 0
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
6
6
6
6
7
7
7
7
8
8
8
8
9
9
9
9
0
0
0
0
Z
62046 Revised 8/2011
Course Number
Completion Date
Submit this form to the Provider at the end of the course if you wish to earn and maintain ASHA CEUs through the ASHA CE Registry (annual fee required). If not an ASHA member or CCC holder, you must be licensed or credentialed to practice speech-language pathology (SLP) or audiology or preparing to practice to earn ASHA CEUs.
Name ____________________________________________
Licensed: _______________________________________________________
Address __________________________________________
(State and License #)
City ________________________________ State _______
Certified: _______________________________________________________ (State/Organization and #)
Clinical Fellow: __________________________________________________ (Supervisor name and her/his ASHA account number)
Zip _______________ Country ______________________ Daytime Phone (_____)______________________________
Enrolled in a graduate program in SLP or audiology: _______________________________________
(Include Area Code)
E-mail Address ____________________________________
(University name and expected graduation date) Please enter your last name (as it appears on your ASHA id card) below. Enter the letters in the spaces provided in the 1st row and fill the entire box that corresponds to the letter in each column.
ASHA Account Number You must provide your ASHA Account Number.
Last Name (Only)
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
H
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
J
J
J
J
J
J
J
J
J
J
J
J
J
J
J
J
J
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
V
V
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Y Z
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
Z
V
Y
1 2 3 4 5 6 7 8 9 0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
6
6
6
6
6
6
6
6
7
7
7
7
7
7
7
7
8
8
8
8
8
8
8
8
9
9
9
9
9
9
9
9
0
0
0
0
0
0
0
0
To update your address or phone number, or to obtain your ASHA Account Number call ACTION CENTER at 1-800-498-2071 between 8:30am and 5:00pm. E.T.
Provider Use Only Complete only for those participants receiving less than the maximum number of ASHA CEUs (i.e., partial credit). Please fill in leading zeros followed by the number of ASHA CEUs. For example, to indicate a participant earned .55 ASHA CEU's (that is, 5 1/2 hours) write 0055.
1 2 3 4 5 6 7 8 9 0
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
6
6
6
6
7
7
7
7
8
8
8
8
9
9
9
9
0
0
0
0
Z
62046 Revised 8/2011
