CEH Provider Request Form

CEH Request Form

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Education Provider Information

All information submitted will be reviewed for approval by IIBEC's education team. No advertisement or promotion of IIBEC CEHs is permitted until written approval is received from the IIBEC education team.

Select your organization type(Required)

IIBEC Chapter

Other Provider

If submitting on behalf of a branch, please select, "IIBEC Chapter"

Chapter Name (Branch name if applicable)(Required)

Organization Name(Required)

Primary Chapter/Branch Contact Name(Required)

First Last

Primary Contact(Required)

First Last

Chapter/Branch Position(Required)

Example: Chapter President, Education Director, Chapter Education Committee Chair, etc.

Organization Role/Title(Required)

Example: Administrator, Manager, Director, Sales Manager, etc.

Primary Chapter/Branch Contact Email Address(Required)

Primary Contact Email Address(Required)

Primary Chapter/Branch Contact Phone Number(Required)

Primary Contact Phone Number(Required)

Is there a secondary chapter or branch contact for this education course/program?(Required)

Yes

Note: any additional individuals listed as secondary contacts for this education course/program will receive email communications from the IIBEC Education Team, including communications regarding this application approval status.

Is there a secondary contact for this education course/program?(Required)

Yes

Secondary Contact Name(Required)

First Last

Secondary Contact Name(Required)

First Last

Secondary Contact Name(Required)

First Last

Chapter/Branch Position(Required)

Example: Chapter President, Education Director, Chapter Education Committee Chair, etc.

Organization Role/Title(Required)

Example: Administrator, Manager, Director, Sales Manager, etc.

Secondary Contact Email Address(Required)

Is there another chapter or branch contact for this education course/program?(Required)

Yes

Note: any additional individuals listed as contacts for this education course/program will receive email communications from the IIBEC Education Team, including communications regarding this application approval status.

Is there another contact for this education course/program?(Required)

Yes

Chapter/Branch Contact Name(Required)

First Last

Contact Name(Required)

First Last

Chapter Role/Position(Required)

Example: Chapter President, Education Director, Chapter Education Committee Chair, etc.

Organization Role/Title(Required)

Example: Administrator, Manager, Director, Sales Manager, etc.

Contact Email Address(Required)

Educational Session #1: Course/Program Title(Required)

Course Start Date(Required)

MM slash DD slash YYYY

Course End Date(Required)

MM slash DD slash YYYY

Is there an online registration page or website for this course/program?(Required)

Yes

Registration website/page(Required)

Number of anticipated attendees/learners(Required)

Will this event offer more than one educational session that you will be requesting CEH approval for?(Required)

Yes

If yes, you will be prompted to submit the below for each additional educational session (up to four sessions).

IIBEC CEHs are approved based on hours of education/instruction and in increments of .50 hours.

Example: If the education course runs from 8:00 a.m.-12:00 p.m., with one coffee break taking place between 10:00 a.m.-10:30 a.m, the total CEH request is 3.5 hours.

Number of IIBEC CEHs requested(Required)

Will this course be offered in one format or multiple formats?(Required)

One format

Multiple formats (example: live in-person and online on-demand)

Select the format of the course.(Required)

Live in-person

Live virtual (i.e., webinar)

On-demand (i.e., online course)

Other course format (explain below)

Select the formats for this course.(Required)

Live-in person

Live virtual (i.e., webinar)

On-demand (i.e., online)

Other (explain below)

Other course format: input an explanation in the space below(Required)

Has this course been previously approved by IIBEC?(Required)

Yes

Courses must have been approved by IIBEC within the last three years.

I attest that the learning objectives and program description have not been modified in any way since IIBEC's previous approval.(Required)

YES, I agree

NO, I disagree. The learning objectives and/or description for this activity have been modified since previously approved by IIBEC.

If the answer to both this and the above question is yes, please proceed to submit your request. If the answer to either is no, please continue with the form as required.

Education Program Agenda/Schedule

Upload a copy of the program agenda/schedule. Note that this agenda/schedule should include the start/stop time of the education as well as any breaks (meals, coffee, etc.) that will occur throughout the program. This agenda/schedule is used to calculate the total hours of education being sought for IIBEC CEH approval.

File(Required)

Max. file size: 32 MB.

Learning Objectives

Learning Objective #1: At the conclusion of this activity, the learner will be able to:(Required)

Learning Objective #2: At the conclusion of this activity, the learner will be able to:(Required)

Learning Objective #3: At the conclusion of this activity, the learner will be able to:(Required)

Learning Objective #4: At the conclusion of this activity, the learner will be able to:(Required)

Learning Objective #5 (optional)

Content Description

In the space below, input 3-5 sentences that provide an overview of the topic(s) that will be covered during the educational activity. Consider: how will the learning objectives be met?(Required)

Checking for Understanding: Please input a brief explanation of the method(s) that will be used to check for learner understanding/comprehension. This may include: a summative assessment or quiz, instructor-led review questions throughout the instruction, polling questions, etc.(Required)

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Education Session #2

Education Session #2 Title(Required)

Education Session #2: Number of IIBEC CEHs Requested(Required)

Education Session #2: Will this course be offered in one format or multiple formats?(Required)

One format

Multiple formats (example: live in-person and online on-demand)

Education Session #2: Select the format of the course.(Required)

Live in-person

Live virtual (i.e., webinar)

On-demand (i.e., online course)

Other course format (explain below)

Education Session #2: Select the format of the course.(Required)

Live in-person

Live virtual (i.e., webinar)

On-demand (i.e., online course)

Other course format (explain below)

Education Session #2: Has this course been previously approved by IIBEC within the last three years?(Required)

Yes

Education Session #2: I attest that this presentation has not been modified in any way since IIBEC's previous approval.(Required)

YES, I agree

NO, I disagree. This presentation has been modified since previously approved by IIBEC.

If the answer to both this and the above question is yes, please proceed to submit your request. If the answer to either is no, please continue with the form as required.

Education Session #2: Learning Objectives

Education Session #2: Learning Objective #1 - At the conclusion of this education activity, the learner will be able to:(Required)

Education Session #2: Learning Objective #2 - At conclusion of this education activity, the learner will be able to:(Required)

Education Session #2: Learning Objective #3 - At the conclusion of this activity, the learner will be able to:(Required)

Education Session #2: Learning Objective #4 - At the conclusion of this activity, the learner will be able to:(Required)

Education Session #2: Learning Objective #5 (optional)- at the conclusion of this activity, the learner will be able to:

Education Session #2 - Content Description

Education Session #2: Content Overview: In the space below, input 3-5 sentences that provide an overview of the topic(s) that will be covered during the educational activity. Consider: how will the learning objectives be met?(Required)

Education Session #2: Checking for Understanding: Please input a brief explanation of the method(s) that will be used to check for learner understanding/comprehension. This may include: a summative assessment or quiz, instructor-led review questions throughout the instruction, polling questions, etc.(Required)

Does this event have another session that you need to submit a CEH request for?(Required)

Yes

Education Session #3

Education Session #3: Title(Required)

Education Session #3: Number of IIBEC CEHs Requested(Required)

Education Session #3: Will this course be offered in one format or multiple formats?(Required)

One format

Multiple formats (example: live in-person and online on-demand)

Education Session #3: Select the format of the course.(Required)

Live in-person

Live virtual (i.e., webinar)

On-demand (i.e., online course)

Other course format (explain below)

Education Session #3: Has this course been previously approved by IIBEC within the last three years?(Required)

Yes

Education Session #3: I attest that this presentation has not been modified in any way since IIBEC's previous approval.(Required)

Yes, I agree

No, I disagree. This presentation has been modified since previously approved by IIBEC.

If the answer to both this and the above question is yes, please proceed to submit your request. If the answer to either is no, please continue with the form as requested.

Education Session #3: Learning Objectives

Education Session #3: Learning Objective #1 - At the conclusion of this activity, the learner will be able to:(Required)

Education Session #3: Learning Objective #2 - At the conclusion of this activity, the learner will be able to:(Required)

Education Session #3: Learning Objective #3 - At the conclusion of this activity, the learner will be able to :(Required)

Education Session #3: Learning Objective #4 - At the conclusion of this activity, the learner will be able to:(Required)

Education Session #3: Learning Objective #5 - At the conclusion of this activity, the learner will be able to:

Education Session #3: Content Description

Education Session #3: Content Description - In the space below, input 3-5 sentences that provide an overview of the topic(s) that will be covered during the educational activity. Consider: how will the learning objectives be met?(Required)

Education Session #3: Checking for Understanding - Please input a brief explanation of the method(s) that will be used to check for learner understanding/comprehension. This may include: a summative assessment or quiz, instructor-led review questions throughout the instruction, polling questions, etc(Required)

Please input a brief explanation of the method(s) that will be used to check for learner understanding/comprehension. This may include: a summative assessment or quiz, instructor-led review questions throughout the instruction, polling questions, etc.

CEH Provider Request Form

CEH Request Form

Education Provider Information

Education Program Agenda/Schedule

Learning Objectives

Content Description

Education Session #2

Education Session #2: Learning Objectives

Education Session #2 - Content Description

Education Session #3

Education Session #3: Learning Objectives

Education Session #3: Content Description

For questions, please contact Director of Education, Kristen Kennedy.