PROFESSIONAL FIDUCIARY ASSOCIATION OF CALIFORNIA For Questions Contact: Phone: (916) 930-9900 · Fax: (916) 916-930-9902 · E-mail: [email protected] APPLICATION FOR ACCREDITATION OF AN INDIVIDUAL COURSE ACTIVITY Please submit application and all required attachments. PROVIDER: PROFESSIONAL FIDUCIARY ASSOCIATION OF CALIFORNIA SAN MATEO COUNTY CHAPTER/NO-CAL REGION CHAPTER/REGION:___________________________________________________________________________ 630 N. SAN MATEO DRIVE, SAN MATEO, CA 94401 ADDRESS:___________________________________________________________________________________ SAN MATEO CA 94401 CITY:_________________________________________ STATE: ___________________ ZIP:________________ 650-342-3523 650-240-1515 PHONE:_________________________________________ FAX:_______________________________________ [email protected] E-MAIL:_____________________________________________________________________________________ Overview of the Biological Basis of Schizophrenia TITLE OF COURSE:____________________________________________________________________________ Friday, November 21, 2014 DATE(S) OF COURSE:__________________________________________________________________________ Hobees Restaurant, Belmont, CA LOCATION(S) OF COURSE:______________________________________________________________________ LEVEL OF DIFFICULTY – CONTENT OF COURSE IS APPROPRIATE FOR: newly licensed or unlicensed Fiduciaries experienced Fiduciaries both newly licensed and experienced Fiduciaries Attorneys HAS THIS COURSE BEEN PREVIOUSLY APPROVED FOR PFAC CONTINUING EDUCATION CREDIT OR CALIFORNIA MCLE CREDIT? Yes No If yes, which Provider/where/when(s)?____________________________________________________________________ If so, whish Provider/where/when(s)?_____________________________________________________________________ REGISTRATION FEE – How much will you charge to attend this course? Free of charge Fee of $___________________________________ 35.00 Required Attachments – Complete all items on the checklist in support of your application: All items required at time of submission - incomplete applications will be returned ✔ 1. AGENDA- Attach a final version of the timed agenda or timed outline of the course. The agenda/outline must include the topics presented, the time allotted to each topic, breaks (if any) and the presenter(s) of each topic/session. ✔ 2. BROCHURE- Attach a brochure, advertisement, eFlier or announcement for the course. If not available, attach a course description. ✔ 3. FACULTY INFORMATION- Attach a biography/CV for each faculty member indicating their professional credentials and/or practical experience/practice area related to the presentation. The biography should include educational background, degrees earned and, for attorneys, their area of practice. ✔ 4. WRITTEN MATERIALS- Attach a printed copy of the complete set of written materials distributed to attendees. Please organize and label the materials so that they correspond to each topic/session listed on the agenda. Note: Written materials must be distributed to attendees at or before the start of the course, not afterwards. Written materials must specifically address each topic presented. Brief outlines do not meet the standards for accreditation. ✔ 5. TIME/CATEGORIES- Indicate total minutes of instruction for which you seek PRAC CEU credit (not including breaks, meals or introductions) in each of the applicable categories: Ethics, Person, Estate and Trusts. 1 Dr. William Faustman, Ph.D., C. Psychol PROVIDER: ____________________________________________________________________________ Overview of the Biological Basis of Schizophrenia TITLE OF COURSE: _____________________________________________________________________ 6. CEU CATEGORY - Ethics Person Estate Trusts 7. AUDIENCE- Describe the audience to which the course is directed and advertised. If open to nonmembers, you must list the 90 other professional groups invited, estimate the percentage of PFACS in the audience ( ____________%) and explain how each session of the course (for which you seek PFAC CEU and/or MCLE credit) will help Professional Fiduciaries improve their skills and attorneys, as attorneys, improve their legal skills. Attach additional sheets if necessary. 8. FORMAT/METHOD OF PARTICIPATION- Select the format(s) in which the course will be presented. Then, for each format, select the method(s) by which attendees will participate. Live: Traditional live classroom setting Online: Class Seminar Seated together in a group setting Conference If you do not see your format or method of participation listed above, please attach a separate sheet and describe it in detail. 9. ATTENDANCE VERIFICATION- For each selection above, please describe the procedures you will use to verify the Attendance of participants. Note: Where participants are seated together in a group setting, attendance is often verified by using a sign in/sign out sheet. (For multi-day, multi-session programs, a separate sign in/sign out sheet will be needed for each session.) 10. DISTRIBUTION OF MATERIALS/EVALUATIONS-State how you will distributewritten materials and evaluation questionnaires to participants. Note: Written materials must be distributed at or before the start of the program, not afterwards. The evaluation survey should address the content, instruction and written materials of the course, and, where applicable, the physical setting and/or technology. 11. NUMBER OF CEUs REQUESTED___________. 1 CERTIFICATION: (A)Provider acknowledges and agrees to comply with all PFAC Program Rules and CEU/MCLE Guideline and Standards. Provider understands that the Program Rules and the CEU/MCLE Guidelines and Standards are available on the PFAC/MCLE website and that printed copies are available by contacting the PFAC Education Commitee. (B) Provider certifies that the faculty of this program includes no PFAC members removed from membership or disbarred attorneys. (C) Provider certifies that this application is complete and includes all required attachments. (D) Provider certifies that the above information (including all information contained in attachments) is true. Vicki L DeVol Treasurer _______________________________________________________________ PROVIDER REPRESENTATIVE (print name) TITLE _______________________________________________________________ SIGNATURE DATE TO AVOID HAVING YOUR APPLICATION RETURNED, PLEASE RESPOND TO ALL QUESTIONS AND INCLUDE ALL REQUIRED ATTACHMENTS. PROGRAM IS APPROVED FOR ________ UNIT/S OF PFAC CONTINUING EDUCATION CREDIT/S PROGRAM IS APPROVED FOR ________ UNIT/S OF MCLE CONTINUING EDUCATION CREDIT/S PROGRAM IS APPROVED FOR ________ WITH THE ATTACHED REVISIONS. (Please see attached) PROGRAM DOES NOT MEET PFAC CEU OR MCLE GUIDELINES AND STANDARDS Vetted By:________________________________ Reset Form 2 Date:________________________ Please remember to include all required attachments (see bottom of page 1) (1) Timed agenda (2) Brochure/Course announcement (3) Faculty biographies (4) Written materials A complete set of written materials for the course should be included with your application. Please keep in mind that the written materials for a Continuing Education course should: · specifically address each topic presented in the course · reflect that they are timely · be thorough, high quality, readable and carefully prepared · cover those matters that one would expect for a comprehensive and professional treatment of the subject matter of the course NOTE: Brief outlines do not meet the standards for accreditation. 3