Effective Jan. 1, 2013 only the newly revised
November 2012 CE Application will be accepted.
November 2012
Thank you for your interest in obtaining continuing education credit for your event/workshop from the Oregon
Chapter, NASW. Please refer to the Program Application Criteria in this packet to assist you in understanding the
level of conference content and relevant social work topics if needed.
The state of Oregon requires social workers practicing at the bachelors, masters and clinical/LCSW social work
levels to seek licensure and continuing education. The NASW of Oregon certifies conferences and workshops in the
continuing education categories of non-clinical, clinical, ethics and supervision. Please see the State Board of
Licensed Social Workers Oregon Administrative Rules Chapter 877 at
http://www.oregon.gov/BLSW/pdfs/12_29_2011_final_rules.pdf
Please complete the following Application for Professional Social Work Continuing Education Credit, including
Attachment A: CEU Application Worksheet in its entirety.
The CE application fee is different for “profit” and “non-profit” sponsors and is graduated according to the number
of hours approved. Please call the office to discuss this non-profit rate or with questions. NASW will send an invoice
to you. The CE application fee for a “profit” sponsor is: $190 for 1-7.5 CE hours; $280 for 8-16 CE hours, $400 for
17-25 CE hours, $450 for 26-55 CE hours, $500 for 56-99 CE hours, $630 for 100-150 hours and $790 for 151-200 CE
hours.
For a “non-profit” sponsor who is not charging for the conference, the CE application fee is: $95 for 1-7.5 CE hours,
$140 for 8-16 CE hours, $200 for 17-25 CE hours, $225 for 26-55 CE hours, $250 for 56-99 CE hours, $315 for 100150 and $345 for 151-200 CE hours.
We request that applications be sent by e-mail to Janet Kusyk at JK@nasworegon.org at least three to four weeks
prior to the training. Completed applications received two weeks (10 business days or less) before the date of the
workshop will be assessed a late fee of $25.
The Chapter will review your application and contact you by e-mail with its determination. If your conference is
approved, you will need to have attendees requesting CE credit complete an NASW conference evaluation form and
sign a conference roster indicating their completion of the conference. Your approval letter, CE certificates,
evaluation forms and conference roster will be e-mailed to you approximately two weeks prior to your event, time
permitting. Your forthcoming approved conference/workshop will be posted on the NASW Oregon Web site if you
request it on your application. If you wish to repeat this workshop (same speaker, content, etc.) within 12
months, there is a per repeated workshop fee of $50 for nonprofits and $80 for profit sponsors. Email
JK@nasworegon.org with your request.
It is the responsibility of the event/workshop sponsor to mail (please, do not e-mail or fax) attendance rosters and
evaluations to the NASW office (2929 SW Multnomah Blvd., Ste. 204, Portland, OR, 97219) upon completion of the
training. NASW will maintain these documents in its chapter files.
Again, we appreciate your interest in the NASW Oregon Chapter’s Continuing Education Program. Please contact
our office at (503) 452-8420 if you have further questions.
Sincerely,
Janet D. Kusyk
Janet D. Kusyk. Continuing Education Coordinator, jk@nasworegon.org
Application for Professional
For office use only:
Social Work Continuing
Date Rec. _______/________/________
Education Credit
Data Entry_____ _/______/_______
No.__________________ Fee $____________
PDF_______/_______/_______or E-mail ______/______/______
Date Paid ______/______/_______
Revised November 2012
Please save this as a Microsoft Word document or PDF and send via e-mail to JK@nasworegon.org.
Please type or print legibly.
Date of Application _________________Prepared by ______________________________________________
Title of Event ______________________________________________________________________________
Sponsor(s)________________________________________________________________________________
Event Date(s) _____________________________________________________________________________
Event Locations(s) ___________________________________ City _______________________ State _____
Target Audience ___________________________________________________________________________
Will there be a registration fee(s)? Yes No
Registration Fee(s) $________________________________________________________________________
Registration Telephone (____) ________________________________________________________________
Web site _________________________________________________________________________________
E-mail for registration inquiries ________________________________________________________________
Estimated number of attendees ___________
Total estimated number of CE hours requested for approval. ________
Is this an "in service" (open to other social workers) event? Yes
Do you request this event be listed on the NASW Website? Yes
No
No
1. If diversity, cultural competence, social justice and/or anti-oppressive practice will be addressed, please
describe how.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________________________________________
2. Attach a brief agenda (including breaks and lunch) that includes dates and time frames for each agenda
item or send a training flyer/brochure that carries this required information.
3. Attach a short paragraph (DO NOT send resumes) on each presenter describing the presenter's
qualifications to present on his or her topic. Please include name, title, degrees, current and former work
experience in topic area, etc.
4. Complete all information requested on Attachment A: CEU Application Worksheet
5. Please feel free to send additional information as a Microsoft Word document or PDF.
Have you determined that the physical facilities for this event are ADA compatible for participants?
 Facilities are ADA compatible
 Not ADA compatible or undetermined as of this date
Please add any further information that would be valuable to the CE Committee.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Name/address of person to whom the CE certificates should be emailed:
Name __________________________________________________________________________________
Organization_____________________________________________________________________________
Address ________________________________________________________________________________
City _______________________________________________ State _________ Zip __________________
E-mail ______________________________ Phone (___) ________________Fax (___) _______________
Name/address of person to whom the invoice should be emailed:
Name __________________________________________________________________________________
Organization_____________________________________________________________________________
Address ________________________________________________________________________________
City _______________________________________________ State _________ Zip __________________
E-mail ______________________________ Phone (___) ________________Fax (___)________________
After completing this form, including Attachment A, the CEU Application Worksheet, please e-mail both
and any additional information to Janet Kusyk, jk@nasworegon.org. An invoice will be e-mailed.
Late Fee Notice: Completed applications received two weeks (10 business days or less) before the training
date will be assessed a late fee of $25, which will be added to the application fee invoice sent by NASW.
Application fees and payment information on next page.
Application Fees and Payment Information:
Profit Sponsor Fees
For a “profit” sponsor: $190 for 1-7.5 CE hours; $280 for 8-16 CE hours, $400 for 17-25 CE hours,
$450 for 26-55 CE hours, $500 for 56-99 CE hours, $630 for 100-150 hours and $790 for 151-200 CE
hours.
Non-Profit Sponsor Fees
For a “non-profit” sponsor who is not charging for the conference the CE application fee: $95 for 1-7.5
CE hours, $140 for 8-16 CE hours, $200 for 17-25 CE hours, $225 for 26-55 CE hours, $250 for 5699 CE hours, $315 for 100-150 and $345 for 151-200 CE hours.
Payment
The chapter will send you an invoice for the application fee. Checks or money orders should be made
payable to: Oregon Chapter, NASW and mailed to the chapter office, 2929 SW Multnomah Blvd.,
Suite 204, Portland, OR 97219.
When sending additional material or a payment to NASW, the workshop’s title and date should be
clearly visible.
Repeat Fee
If you wish to hold this workshop again within 12 months of the workshop date, there is a per repeated
workshop fee of $50 for nonprofits and $80 for profit sponsors.
Please call the chapter office at (503) 452-8420 for questions or information.
Incomplete applications will not be processed until all information is received.
Revised November 2012
Attachment A: CEU Application Worksheet
Page 1 of _____
Training Title: ____________________________________________________
_________________________________________________________________
Training Date(s): ___________________________________________________
Worksheet Completed by: ____________________________________________
Tele._____________________________________________________________
Email_____________________________________________________________
Time frame for each
workshop1 (Do not include
time for introduction, breaks
or lunch break)
Speaker/Credentials/
Licensure
Workshop Title & Brief
Description
Non-Clinical
Social Work
Practice
# of CEUs2
1. Provide the start and end time for each workshop.
2. Non-Clinical Social Work Practice CEUs—Number of hours with content
pertaining to the practice of social work in general .
3. Clinical Social Work Practice CEUs—Number of hours with content
pertaining to the prevention, assessment, treatment or diagnosis of mental
disorders. See page 2 of the Program Application Criteria for more
information.
4. Social Work Ethics CEUs—Number of hours with content pertaining to ethics,
laws and administrative rules of practicing social work.
5. Social Work Supervision CEUs—Number of hours with content pertaining to
supervising the practice of social work.
6. Learning Objectives—State how each workshop meets the objectives of each
workshop’s content.
Clinical Social
Work Practice
Social Work
Ethics
Social Work
Supervision
# of CEUs3
# of CEUs4
# of CEUs5
Learning Objectives6
Attachment A: CEU Application Worksheet
Page 2 of _____
Training Title: ____________________________________________________
_________________________________________________________________
Training Date(s): ___________________________________________________
Worksheet Completed by: ____________________________________________
Tele._____________________________________________________________
Email_____________________________________________________________
Time frame for each
workshop1 (Do not include
time for introduction, breaks
or lunch break)
Speaker/Credentials/
Licensure
Workshop Title & Brief
Description
Non-Clinical
Social Work
Practice
# of CEUs2
1. Provide the start and end time for each workshop.
2. Non-Clinical Social Work Practice CEUs—Number of hours with content
pertaining to the practice of social work in general .
3. Clinical Social Work Practice CEUs—Number of hours with content
pertaining to the prevention, assessment, treatment or diagnosis of mental
disorders. See page 2 of the Program Application Criteria for more
information.
4. Social Work Ethics CEUs—Number of hours with content pertaining to ethics,
laws and administrative rules of practicing social work.
5. Social Work Supervision CEUs—Number of hours with content pertaining to
supervising the practice of social work.
6. Learning Objectives—State how each workshop meets the objectives of each
workshop’s content.
Clinical Social
Work Practice
Social Work
Ethics
Social Work
Supervision
# of CEUs3
# of CEUs4
# of CEUs5
Learning Objectives6
Attachment A: CEU Application Worksheet
Page 3 of _____
Training Title: ____________________________________________________
_________________________________________________________________
Training Date(s): ___________________________________________________
Worksheet Completed by: ____________________________________________
Tele._____________________________________________________________
Email_____________________________________________________________
Time frame for each
workshop1 (Do not include
time for introduction, breaks
or lunch break)
Speaker/Credentials/
Licensure
Workshop Title & Brief
Description
Non-Clinical
Social Work
Practice
# of CEUs2
1. Provide the start and end time for each workshop.
2. Non-Clinical Social Work Practice CEUs—Number of hours with content
pertaining to the practice of social work in general .
3. Clinical Social Work Practice CEUs—Number of hours with content
pertaining to the prevention, assessment, treatment or diagnosis of mental
disorders. See page 2 of the Program Application Criteria for more
information.
4. Social Work Ethics CEUs—Number of hours with content pertaining to ethics,
laws and administrative rules of practicing social work.
5. Social Work Supervision CEUs—Number of hours with content pertaining to
supervising the practice of social work.
6. Learning Objectives—State how each workshop meets the objectives of each
workshop’s content.
Clinical Social
Work Practice
Social Work
Ethics
Social Work
Supervision
# of CEUs3
# of CEUs4
# of CEUs5
Learning Objectives6
Attachment A: CEU Application Worksheet
Page 4 of _____
Training Title: ____________________________________________________
_________________________________________________________________
Training Date(s): ___________________________________________________
Worksheet Completed by: ____________________________________________
Tele._____________________________________________________________
Email_____________________________________________________________
Time frame for each
workshop1 (Do not include
time for introduction, breaks
or lunch break)
Speaker/Credentials/
Licensure
Workshop Title & Brief
Description
Non-Clinical
Social Work
Practice
# of CEUs2
1. Provide the start and end time for each workshop.
2. Non-Clinical Social Work Practice CEUs—Number of hours with content
pertaining to the practice of social work in general .
3. Clinical Social Work Practice CEUs—Number of hours with content
pertaining to the prevention, assessment, treatment or diagnosis of mental
disorders. See page 2 of the Program Application Criteria for more
information.
4. Social Work Ethics CEUs—Number of hours with content pertaining to ethics,
laws and administrative rules of practicing social work.
5. Social Work Supervision CEUs—Number of hours with content pertaining to
supervising the practice of social work.
6. Learning Objectives—State how each workshop meets the objectives of each
workshop’s content.
Clinical Social
Work Practice
Social Work
Ethics
Social Work
Supervision
# of CEUs3
# of CEUs4
# of CEUs5
Learning Objectives6