Record Keeping Form for Certification Maintenance Hours (CMH) Audit
Please do not report the CEUs that are included on your CE Registry Transcript
Name: ____________________________________ ASHA ID #: 3-year maintenance interval: _______________
Area of certification: Audiology Speech-Language Pathology Dually certified
Instructions
List each of your professional development activities on a separate line. Be sure the activities were completed during your 3-year maintenance interval.
Calculate the CMHs.
.1 CEU = 1 CMH 1 CEU = 10 CMHs 1 quarter hour of university
course work = 10 CMHs
1 semester hour of university
course work = 15 CMHs
Be sure to attach the documentation of participation/attendance/completion for each activity you list on the Record Keeping form.
Incomplete Record Keeping forms and/or documentation will delay your certification maintenance process.
If you have questions, please call 800-498-2071or send an email to certification@asha.org
.
You may send your form and supporting documentation to: ASHA, attn: Certification Unit, 2200 Research Blvd. #313, Rockville, MD 20850-3289
Activities will not be accepted without appropriate documentation*
Title of Activity Completion
Date
Sponsoring
Organization/Third Party
Number of
CMHs
Documentation of
Participation*
Office Use
Only
*Documentation Required for Audit: Acceptable documentation of participation is a copy of a certificate of participation, a copy of a letter of participation, a copy of the
college transcript, and/or a copy of a transcript of activities from other professional organizations. Sign-in sheets, registration fees receipts, and/or course descriptions
and brochures are not acceptable. If you cannot get acceptable documentation for CMH activities, you will not be able to use those activities.
Revised 2/09
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