UNIT VERIFICATION FORM
CPE/T Unit Verification Form - must be completed by the Training Supervisor
Email address *
CLINICAL SUPERVISOR
CLINICAL SUPERVISOR'S NAME *
Clinical Supervisor's Email: *
Clinical Supervisor's Phone Number: *
Is the Clinical Supervisor a Supervisor-In-Training (SIT)? *
Required
If you answered "YES", above, please provide the Training Supervisor's name, email address, and phone number.
Chapter: *
TRAINING CENTER
Training Center Name: *
Street Address (Mailing Address): *
City: *
State: *
ZIP Code: *
TRAINING SUPERVISOR
Training Supervisor's Name: *
Training Supervisor's Chapter: *
Training Supervisor's Email Address: *
Training Supervisor's Phone Number: *
Street Address (Mailing Address): *
City: *
State: *
ZIP Code *
TRAINEE & UNIT INFORMATION
TRAINEE #1
#1 Name of Trainee
#1 Units Completed
#1 Ministry/Clinical Site
#1 Dates of Training
TRAINEE #2
#2 Name of Trainee
#2 Units Completed
#2 Ministry/Clinical Site
#2 Dates of Training
TRAINEE #3
#3 Name of Trainee
#3 Units Completed
#3 Ministry/Clinical Site
#3 Dates of Training
Trainee #4
#4 Name of Trainee
#4 Units Completed
#4 Ministry/Clinical Site
#4 Dates of Training
TRAINEE #5
#5 Name of Trainee
#5 Units Completed
#5 Ministry/Clinical Site
#5 Dates of Training
TRAINEE #6
#6 Name of Trainee
#6 Units Completed
#6 Ministry/Clinical Site
#6 Dates of Training
TRAINEE #7
#7 Name of Trainee
#7 Units Completed
#7 Ministry/Clinical Site
#7 Dates of Training
TRAINEE #8
#8 Name of Trainee
#8 Units Completed
#8 Ministry/Clinical Site
#8 Dates of Training
This form must be submitted by the Training Supervisor
A copy of your responses will be emailed to the address you provided.
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