School of Social Work Loyola University Chicago by WOil0uwJ

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									                     Loyola University Chicago School of Social Work
                             820 N. Michigan Ave. ♦ Chicgao, Il, 60611
    Request for Certification of Continuing Education Credits for Teaching

Name:_______________________________________ License Number: _____________________
Address: ______________________________________City/State/Zip: _______________________
Phone number:_________________________________ E-mail: ____________________________


Title and course number of course taught (circle one):
   Social Work 530- 531 1st level field course (circle this if you supervised a BSW or first level student)
   Social Work 630-631 2nd level field course (circle this if you supervised a second level student)
   Social Work 640-641 Post Master’s field course (circle this if you supervised a post master student)
Dates taught: _____________ to ____________________

Name of agency/organization (including specific division):_____________________________________

____________________________________________________________________________________

Agency/organization address:____________________________________________________________

Phone number of agency:_____________________

Number of actual hours teaching: __________(30 hours = maximum amount of hours)
Number of teaching CEU’s earned (1.5 x actual teaching hours): 45 CEU’s

You may only receive 45 CEUs for teaching a each level field course once. (If you received 45 CEU’s for
teaching, 530-531, you may also receive 45 CEUs for teaching a 630-631 2nd level field course and a 640-641
post-master student.

Please certify, by signing below, that this is the only time that you have claimed credit hours for teaching the
particular course circled above:

Signature: _____________________________________ Date: ___________________

Please write the name(s) of the student(s) supervised this year:______________________________________

NOTE: There is a $15 fee to process this CEU request. You may make this payment online or by check.
To pay online, please go to www.luc.edu/socialwork/payments. Under the left heading, you will see CEUs
and Workshops. Click on CEU's for Field Instruction. Checks are payable to LUC School of Social Work.
This form cannot be processed until the student intern has completed the required number of fieldwork hours
at his/her field placement.

Please return form to by fax, mail or e-mail.
Fax: 312-915-7090,
E-mail: bbulliner@luc.edu
Mail: Dept. of Internships, Programs and Student Services, School of Social Work, Loyola University
Chicago, 820 N. Michigan Ave., Chicago, IL 60611.


Revised March 2011

								
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