Self Reporting Submission Form
Personal Information:
Name:
Company:
Position:
Address:
Telephone:
Fax:
NCIDQ Certificate #:
Last 4-digits of SSN:
Have You Attended This Course Before?
Would you like IDCEC to report this course to NCIDQ on your behalf?
E-mail:
 Yes
 Yes
 No
 No
Payment Information:
Please select one organization to manage your IDCEC submission. This organization will ensure your submission materials are
complete and coordinate your IDCEC review with ASID, IIDA, IDC and IDEC.

Mail to:
ASID Education Dept.
608 Massachusetts Ave. NE
Washington, DC 20002

Mail to:
IDC Education Dept.
220 - 6 Adelaide Street East
Toronto, Ontario, M5C 1H6


Mail to:
IDEC Education Dept.
9100 Purdue Road, Suite 200
Indianapolis, IN 46268
Mail to:
IIDA Education Dept.
222 Merchandise Mart, Suite 567
Chicago, IL 60654
The fee for an IDCEC Self Reporting CEU submission is US$50 ($50 Canadian), payable to the organization who is managing your
submission. IDCEC submission fees are not refundable. It can take up to 8 weeks for your IDCEC submission to be processed.
Check: #______
Credit Card:  American Express
 Visa
 MasterCard
Name on Card:
Card Number:
Expiration Date:
Security Code:
Amount Paid:
By signing this form, I understand that my payment is non-refundable, regardless of the outcome of this request for
CEU approval. The final decision on approval rests with IDCEC. I request that IDCEC to submit my course information to NCIDQ for
my CE Transcript. I authorize NCIDQ to add this course to my CE transcript. NCIDQ will record and maintain this information (this
service is reflected in the fee).
Signature:
Date:
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Self Reporting Submission Form
About the Course:
Title:
Date:
Host/Sponsoring Organization:
Target Audience (s):
 Residential
 Office/Corporate
 Health Care
 Hospitality/Entertainment
 Government/Institutional
 Retail/Store Planning
 Facilities Management  Other, ___________________
Estimate Number of Attendees:
Type of Course:
In-person presentation: Lecture
Distance learning course: Web based
Publication
Field Lab
Telephone based
CD/DVD
Description:
Please provide a short description of
the course.
Outline:
Order
In the space provided, please illustrate
the course schedule/syllabus by listing
the topics addressed, any pertinent
sub-topics, in 5, 10 and 15 minute
intervals. Add additional rows as
needed.
Description of Topic/Content
Duration
1
2
3
4
5
6
Total
Learning Outcomes:
Identify at least 3 learning outcomes
that you gained from attending this
course.
1.
2.
3.
Supporting Materials:
Handouts
Submit two photocopies of course materials/handouts. If the course is offered on the Internet,
supply the URL and password so the IDCEC reviewers may evaluate the course in its entirety.
Submissions without supporting materials will not be approved.
 Yes, I have attached two copies of the handouts.
Verification of Attendance
Submit two photocopies of your proof which verifies your attendance at and successful
completion of this course. Appropriate documents, such as an instructor signed certificate of
completion and/or exit letter, must include the duration of the course, provider, date and your
(the participants) name.
 Yes, I have attached two copies of my verification of attendance.
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Interior Design Continuing Education Council  2010
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Self Reporting Submission Form
About the Speaker/Author/Instructor(s):
Name:
Company:
Position:
Address:
Telephone:
E-mail:
Biography:
This brief biography (100 words) about each
instructor is required. Items that should be
included are educational background (degrees,
discipline, university/school, and year of
completion), positions held in academic
institutions (title of position/rank, year and
tenure), positions held in design practice (firm
name, title, and year), Positions held in
businesses that provided experience related to
course subject matter (firm name, title,
description of experience related to course
subject matter and year), awards, recognitions,
grants, competitions, etc
Has this instructor completed a degree in interior design?
Has this instructor passed the complete NCIDQ Exam?
Is the instructor a member of a professional membership organization?
 Yes
 No
 Yes
 No
 Yes
 No
Please specify______________________
Course Evaluation:
To receive IDCEC approval, you must evaluate the course.
Scorecard
Overall Impression:
Quality of Content: (timeliness, relevance, depth)
Speaker’s Presentation Skills: (delivery, visuals, interactivity)
Poor
Deficient
Average
Good
Excellent
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Comments:
Please be sure to submit 2 copies of all forms and course materials.
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