workshop

							2013 Annual Summary of Continuing Education Hours

Continuing education (CE) hours should be in the field of professional chaplaincy and advance
the professional practice or skills of the board certified or associate certified chaplain.
Tip: Save this convenient Word document form on your computer, and record CE throughout the year as you read, attend seminars,
teach, etc. At the end of the year, attach this form to an e-mail and send to info@professionalchaplains.org. Use additional sheets or
add rows to the table as needed.

Name
Place of Work
Address
City, State, Zip                                                                            E-mail
                                       50 CE Hours Required
                                                                                                     I was certified in 2013 and so my CE
   Board Certified Chaplain (BCC)                      Associate Certified Chaplain (ACC)
                                                                                                     hours were pro-rated for 2013.
   Provisional BCC                                     Provisional ACC
   I have read and understand the Continuing Education Program Guidelines and FAQs (required).

                                 Must record CE hours under at least 2 (two) of the following methodologies.

Methodology 1, Attending Educational Events

              Event Type
Date          e.g. workshop,       Title / Topic                                                     Sponsoring Organization       HOURS
              lecture, webinar




                                                                                                           Total Methodology 1



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Methodology 2, Writing
Date          Title / Topic                               Publication/Media         HOURS




                                                              Total Methodology 2

Methodology 3, Teaching
Date          Title / Topic                               Sponsoring Organization   HOURS




                                                              Total Methodology 3

Methodology 4, Professional Self-Care (4 hours maximum)
              Session
Date                          Title / Description                                   HOURS
              Type




                                                              Total Methodology 4



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Methodology 5, Reading / Self-Instruction
Date          Title / Topic                                                                    Author / Publisher       HOURS




                                                                                                  Total Methodology 5

Methodology 6, Own Peer Review (5 hours maximum)
Date          Organization/Institution   Description                                                                    HOURS



                                                                                                  Total Methodology 6

Methodology 7, Service to APC (10 hours maximum)
Date          Description of Service & Educational Component                                                            HOURS




                                                                                                  Total Methodology 7

                                                                                                Total Methodology 1
                                                                                                Total Methodology 2
                                                                                                Total Methodology 3
Please retain a copy of this form for your records.
You do not need to submit CE certificates and other supporting documentation.                   Total Methodology 4

This form must be submitted to BCCI by January 31, 2014                                         Total Methodology 5
                                                                                                Total Methodology 6
                                                                                                Total Methodology 7
                                                                                                GRAND TOTAL

Name:

                 BCCI • 1701 E. Woodfield Rd., Suite 400 • Schaumburg, IL 60173 • www.professionalchaplains.org/bcci
                             847.240.1014 • E-mail: info@professionalchaplains.org • FAX: 847.240.1015


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