audit report LCSW

audit report LCSW

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LOUISIANA STATE BOARD OF SOCIAL WORK EXAMINERS LCSW CONTINUING EDUCATION AUDIT REPORT July 1, 2009 - June 30, 2010 Name:____________________________________________________________________________________ Address:__________________________________________________________________________________ ____________________________________________________________________________________ Credential No.:__________ Telephone: (_______)_____________________ Fax:_______________________ You must list 20 clock hours of continuing education including 10 hours in clinical content covering diagnosis and treatment and 3 hours in social work ethics. Ethics were to be completed between July 1, 2008 and June 30, 2010. Attach documentation verifying your attendance at the events. Please do not use initials when writing the names of the events or sponsoring organizations. Auditor Use Only Hours Month/Day/Year Hours Approved Not Approved Event: __________________________________________________ _______________ ________ _________ _________ __________________________________________________ Presenter: ________________________________________________________________________ Sponsoring Organization: ____________________________________________________________ ...

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LOUISIANA
S
TATE
B
OARD OF
S
OCIAL
W
ORK
E
XAMINERS
LCSW CONTINUING EDUCATION AUDIT REPORT
July 1, 2009 - June 30, 2010
Name:____________________________________________________________________________________
Address:__________________________________________________________________________________
____________________________________________________________________________________
Credential No.:__________ Telephone: (_______)_____________________ Fax:_______________________
You must list 20 clock hours of continuing education including 10 hours in clinical content covering diagnosis
and treatment and 3 hours in social work ethics. Ethics were to be completed between July 1, 2008 and June
30, 2010. Attach documentation verifying your attendance at the events.
Please do not use initials when writing the names of the events or sponsoring organizations.
Event:
__________________________________________________
_______________
________
__________________________________________________
Presenter: ________________________________________________________________________
Sponsoring Organization: ____________________________________________________________
Clinical Content
9
Ethics
9
Supervision
9
Event:
_________________________________________________
_______________
________
_________________________________________________
Presenter: ________________________________________________________________________
Sponsoring Organization: ___________________________________________________________
Clinical Content
9
Ethics
9
Supervision
9
Event:
_________________________________________________
________________ ________
_________________________________________________
Presenter: ________________________________________________________________________
Sponsoring Organization: ___________________________________________________________
Clinical Content
9
Ethics
9
Supervision
9
Auditor Use Only
Hours
Approved
Not Approved
_________
_________
_________
_________
_________
_________
Month/Day/Year
Hours
Event:
____________________________________________
_________________
_______
____________________________________________
Presenter: ______________________________________________________________________
Sponsoring Organization: ___________________________________________________________
Clinical Content
9
Ethics
9
Supervision
9
Event:
______________________________________________
_________________
_______
______________________________________________
Presenter: _______________________________________________________________________
Sponsoring Organization: __________________________________________________________
Clinical Content
9
Ethics
9
Supervision
9
Event:
______________________________________________
_________________
_______
______________________________________________
Presenter: _______________________________________________________________________
Sponsoring Organization: ____________________ ______________________________________
Clinical Content
9
Ethics
9
Supervision
9
Event:
_______________________________________________
_________________
______
_______________________________________________
Presenter: _______________________________________________________________________
Sponsoring Organization: ___________________________________________________________
Clinical Content
9
Ethics
9
Supervision
9
Event:
_______________________________________________
_______________
_______
_______________________________________________
Presenter: _______________________________________________________________________
Sponsoring Organization: ______________________ ____________________________________
Clinical Content
9
Ethics
9
Supervision
9
Event:
_______________________________________________
_______________
_______
_______________________________________________
Presenter: _____________________________________________________________________
Sponsoring Organization: __________________________________________________________
Clinical Content
9
Ethics
9
Supervision
9
Auditor Use Only
Hours
Approved
Not Approved
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
__________
Month/Day/Year
Hours
LICENSEE NAME _______________________________
ADDRESS
_______________________________
_______________________________
________________________________
***************************************************************************
AUDITOR USE ONLY:
_____
An Audit of this licensee’s continuing education report has been completed and the documentation has been found to be
in compliance with all sections of Rule No. 317.
_____
An audit of this licensee’s continuing education report has been completed and has revealed that the documentation is
not in compliance with Rule No. 317 for the following reason(s):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Recommendation: _________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Reviewed by:_____________________________________________
Date:_____________________________
******************************************************************************************************
Questions concerning your AUDIT should be directed to:
A
S
W
B
L
O
U
I
S
IANA-CE AUDIT
PO Box 1508
Culpepper, VA 22701
Phone: 1-866-527-2384
Fax:
1-540-829-0142
Continuing Education Requirements can be viewed on our website
www.labswe.org.
See Rule No. 317 of the
Rules, Standards and Procedures
.