Fillable ACEP Additional Delivery Format Application

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ACEP Additional Delivery Format Application

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PAYMENT
ACEP
Additional Delivery Format Application
ACEP Name: ACEP Number:
ACEP Administrator:
Telephone Number:
E-mail:
Mailing Address:
City, State, ZIP Code:
Programs offered by ACEPs for NBCC credit may be presented in the following program formats, consistent with the
NBCC Continuing Education Provider Policy and the directives of NBCC:
Check the delivery format(s) for which you are applying:
Live Event Delivery Format: Real-time, interactive programs either delivered in person or
by electronic devices that permit the participant to interact with the presenter(s), including
qualified programs delivered solely for in-service training directly related to employment
Home Study Delivery Format: Text-based learning materials, on-demand webinars, and
other audiovisual materials that include an assessment demonstrating that the participant
completed the program
NOTE: Incomplete applications will not be processed. Payment must be received in full prior to review.
Do not mail payment separately.
Return this completed application, the $400 application fee and all accompanying materials to:
NBCC Continuing Education Department
3 Terrace Way
Greensboro, NC 27403
ACEP Additional Delivery Format Application Program Delivery Format
Fee
Application Fee
Includes review of one delivery format
(Either live event or home study)
$400
Application fees are nonrefundable and nontransferable.
FOR OFFICE USE ONLY
REF
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ACEP #: ________________
2
ACEP Number:
Approval Requirements
ACEP
status is granted by NBCC to eligible providers demonstrating compliance with all ACEP provider and program
requirements, including all applicable terms of the NBCC Continuing Education Provider Policy
. NBCC retains the sole
authority to determine if a provider qualifies for ACEP status.
If granted ACEP status, the approved provider is authorized to offer NBCC credit for qualifying programs in the approved
delivery format.
T
he guiding principle and operational goal of the NBCC ACEP process is to identify qualified program providers that are
able to offer qualifying programs consistent with the requirements of the NBCC provider policy. ACEP status is limited to
organizations and individuals that can function independently and have the resources to satisfy all policy requirements.
ACEP Status Eligibility Requirements
In order to qualify for ACEP status, an applicant must satisfy all NBCC ACEP eligibility requirements, including
the following:
(a). The applicant currently develops and presents continuing education programs that would qualify for credit under
the policy.
(b). The applicant must sufficiently demonstrate that the organization or individual offers and presents at least two
different live programs or one home study program that would qualify for NBCC credit under the policy.
(c).The applicant must designate an authorized representative to serve as ACEP administrator.
Among other responsibilities, the ACEP administrator serves as the primary contact person for
NBCC concerning all ACEP program matters.
(d). The applicant must designate a qualified representative to serve as the program administrator. The program
administrator must hold an advanced degree in a mental health field from an accredited educational institution. The
program administrator is responsible for assuring that the content of all provider programs offering NBCC credit and the
qualifications of all program presenters satisfy the requirements of the policy. The program administrator may also serve
as the ACEP administrator.
(e). The applicant must submit a complete ACEP application, including all required information, materials and fees.
All ACEP application materials become the property of NBCC, and fees are not refundable.
(f). The applicant must not display any statement concerning NBCC approval or status prior to written notification of
approval from NBCC.
P
rograms submitted must have been created, developed, advertised, planned and implemented by the applicant. Sessions
presented by the applicant for another provider’s program or conference will not be considered. The applicant cannot
delegate any portion of the application process to another organization. Programs submitted as part of the ACEP application
cannot be from a cosponsorship relationship or a cosponsored program.
ACEP #: ________________
3
Application Requirements
Incomplete or unsigned applications will not be reviewed.
Correct payment must accompany the application.
For Live Event Delivery Format
The applicant organization must sufficiently demonstrate that the provider has previously created,
developed, advertised, planned and implemented at least two different live programs that qualify for credit
under the NBCC Continuing Education Provider Policy.
Submit the following with this application:
1. Completed copies of Attachment A for two different previously offered live event programs;
2. Brochures, agendas and other promotional materials for the programs listed on Attachment A;
3. Evaluation summaries for the programs listed on Attachment A and a blank evaluation form;
4. Presenter Qualification Form accurately identifying all individual and organizational program
presenters, including the qualifications, with relevant academic degree and field of study, of
each presenter;
5. Sample certificates of completion distributed to participants for the programs listed on Attachment A;
6. Curriculum vitae or résumé of program administrator; and
7. The provider’s organizational governance documents and operational principles. If the organization is
incorporated, submit the articles of incorporation and corporate bylaws. If the is a limited liability
company (LLC), please submit the LLC operating agreement. If the provider is a tax-exempt organization,
submit a copy of the IRS determination letter.
For Home Study Delivery Format
The applicant must sufficiently demonstrate that the provider offers and presents at least one home study
program that qualifies for credit under the NBCC Continuing Education Provider Policy.
In order to qualify for NBCC credit, all home study program materials must be of professional quality in
content and appearance, including all audiovisual and print materials. All home study program materials must
be fully functional and accessible to all program participants and NBCC. The applicant must ensure that all
program materials do not infringe upon any privacy or intellectual right of any other party.
ACEP #: ________________
4
NBCC will review the submitted home study program from start to finish. This includes completing the
evaluation, taking the assessment instrument, and obtaining a certificate of completion. The program will
be tested from the user’s perspective and NBCC must be given full, unrestricted access to all aspects of
the program.
Submit with this application the following materials and information:
1. Learning materials, such as text-based, audiovisual or Web-based materials;
2. All necessary URLs, usernames and passwords for complete review of the program from start to finish;
3. Presenter Qualification Form accurately identifying all individual program presenters/authors, including
the qualifications, with relevant academic degree and field of study of each;
4. An explanation of the calculation used to determine the amount of NBCC credit, and if applicable, an
accurate word count of all text-based learning materials;
5. An assessment instrument prepared by a professional with an advanced degree in a mental health field
intended to evaluate the participant’s knowledge of the program material, and a curriculum vitae or
résumé for the author of the assessment instrument;
6. An answer key for the assessment instrument;
7. Instructions clearly explaining the process for obtaining NBCC credit from the provider upon
completion of the program;
8. A reference list accurately identifying all source materials used to prepare the program, such as
professional journal articles or books;
9. An evaluation document for participants to rate the program;
10. A sample certificate of completion for the program;
11. Curriculum vitae or résumé of the program administrator; and
12. The provider’s organizational governance documents and operational principles. If the organization is
incorporated, submit the articles of incorporation and corporate bylaws. If the organization is a limited
liability company (LLC), please submit the LLC operating agreement. If the provider is a tax-exempt
organization, submit a copy of the IRS determination letter.
Each provider offering NBCC credit is solely responsible for submitting to NBCC all required information and
documentation demonstrating that the provider and the provider’s programs are in compliance with the policy.
Providers failing to demonstrate compliance with the policy may be sanctioned by NBCC, including the
disqualification of noncompliant programs or providers, or suspension or termination of ACEP status.
ACEP #: ________________
5
I attest that I understand the NBCC Continuing Education Provider Policy (policy) and that the
information provided in this application and the attachments is complete. If approved as an ACEP, the
provider will comply with the terms set forth in the policy.
Name of Authorized Representative:
Signature: Date:
Send application, required materials and payment form to:
NBCC CE Department
3 Terrace Way
Greensboro, NC 27403-3660.
You may also fax the application, required materials and payment form to 336-547-0017
(Attention: CE Department).
Submission of an application does not guarantee approval. Applications are reviewed in the
order they are received.
Contact continuinged@nbcc.org with questions.
ACEP #: ________________
6
Attachment A
(1)
For Live Event Delivery Format
Submit completed copies of Attachment A for two different previously offered live programs.
Title of Program:
Date Offered:
Presenter(s):
Submit a Presenter Qualification Form for each presenter and identify who presented what material.
Target Audience:
Number of Participants
Estimated Number of Participants
Who Were Master’s-Level
Counselors
Number of Hours of Credit Offered
Program Content Description:
Learning Objectives:
1.
2.
3.
4.
Submit the following with this form:
• Brochures, agendas and other promotional materials for the programs listed;
• Evaluation summaries from the programs listed and a blank evaluation form;
• Completed Presenter Qualification Form for the programs listed along with a curriculum vitae or résumé for each presenter; and
• Sample certificates of completion for the programs listed.
ACEP #: ________________
7
Attachment A
(2)
For Live Event Delivery Format
Submit completed copies of Attachment A for two different previously offered live programs.
Title of Program:
Date Offered:
Presenter(s):
Submit a Presenter Qualification Form for each presenter and identify who presented what material.
Target Audience:
Number of Participants
Estimated Number of Participants
Who Were Master’s-Level
Counselors
Number of Hours of Credit Offered
Program Content Description:
Learning Objectives:
1.
2.
3.
4.
Submit the following with this form:
• Brochures, agendas and other promotional materials for the programs listed;
• Evaluation summaries from the programs listed and a blank evaluation form;
• Completed Presenter Qualification Form for the programs listed along with a curriculum vitae or résumé for each presenter; and
• Sample certificates of completion for the programs listed.
ACEP #: ________________
8
Presenter Qualification Form
In order for a provider to offer NBCC continuing education credit for a program, the subject matter must be directly related
to an NBCC content area and the presenter/author must qualify as a presenter for the subject matter presented, as required by
the NBCC Continuing Education Provider Policy.
Presenter Name:
Title of Program or Session/Workshop:
NBCC content area(s) to which the subject matter of this program is directly related (policy section G):
Select the presenter category appropriate for this individual:
□
Category 1 Presenter
□
Category 2 Presenter
□
Category 3 Presenter
Education
Degree
Major or Field of Study
Institution
Year
Master’s
Doctorate
Other
Describe relevant experience and/or training related to topic presented/authored.
Professional Licenses or Certifications:
A curriculum vitae, résumé or other documentation to verify education, experience and training must be
attached to this form for each presenter.
ACEP #: ________________
9
ACEP Additional Delivery Format Application Payment Authorization
Name of Provider:
Name of Authorized Representative:
ACEP Additional Delivery Format Application Program Delivery Format
Fee
Application Fee
Includes review of one delivery format
(Either live event or home study)
$400
Application fees are nonrefundable and nontransferable.
Check or money order payable to NBCC. (Write “ACEP ####” on the memo line.)
I authorize NBCC to charge the card below in the amount of $ .
Contact continuinged@nbcc.org with questions.
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ACEP Additional Delivery Format Application

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Completed 7 February 2020

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