COMPLETION: INDEPENDENT STUDY 

Submit this form upon completion of your pre-approved Independent Study. 

If more than one Independent Study was pre-approved on the same application form, you may include up to three (3) Independent Studies on this Completion Form. 

The ARCB Continuing Education Committee will notify you whether or not your completion form has been approved. 

Submit this form no later than December 31st of your two-year CE cycle.

If additional space is needed, please submit the materials to ARCBContEduc@gmail.com.

DO NOT USE THIS FORM for ARCB® approved CE coursework.

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First Name *
Last Name *
ARCB Certificant Number *
Your email address *
Mailing Address - Street, City, State, Zip *
Phone Number *
Your 2-year certification period ends December 31 of what year? *
What is the name of the Independent Study(ies) you have completed? *
Was this Independent Study approved by the ARCB CE Committee PRIOR to the start of the Independent Study? *
Did you meet the objectives identified in your application for each Study? *
If NO please explain.
Provide verification of completion of the Independent Study(ies) (written article, curriculum summary, certificate of completion, brief summary, etc.).  Please send documents to ARCBContEduc@gmail.com. *
Number of CE hours completed - listed per Study. *
EDUCATOR - If you developed a new course or program, please submit a brief summary of the course developed, the target population, and when you expect to offer the course. 
WORKED WITH PROFESSIONAL ASSOCIATION - Please describe the type of work you performed and the organization you assisted.  
All statements made herein are true and complete to the best of my knowledge. I understand and agree that misrepresentation or omission will cause forfeiture of any CE hours that may be approved from this application.
 *
ELECTRONIC SIGNATURE - please type your full name below. *
REMEMBER to submit additional materials to ARCBContEduc@gmail.com.
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