audit report LCSW-BACS
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LOUISIANA STATE BOARD OF SOCIAL WORK EXAMINERS LCSW-BACS CONTINUING EDUCATION AUDIT REPORT July 1, 2009 - June 30, 2010 Name:____________________________________________________________________________________ Address:__________________________________________________________________________________ ____________________________________________________________________________________ Credential No.:__________ Telephone: (_______)_____________________ Fax:_______________________ You must list 20 clock hours of continuing education which includes 10 hours in clinical content covering diag-nosis and treatment, 3 hours in social work ethics and 3 hours in clinical supervision. Ethics and clinical super-vision were to be completed between July 1, 2008 and June 30, 2010. Attach documentation verifying your attendance at the events. Please do not use initials when writing the names of the events or sponsoring organizations. Auditor Use Only Hours Month/Day/Year Hours Approved Not Approved _________ _________ Event: __________________________________________________ _______________ ________ __________________________________________________ Presenter: ________________________________________________________________________ Sponsoring Organization: ...
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LOUISIANA STATEBOARDOFSOCIALWORKEXAMINERSLCSW-BACSCONTINUING EDUCATION AUDIT REPORT July 1, 2009 - June 30, 2010 Name:____________________________________________________________________________________ Address:__________________________________________________________________________________ ____________________________________________________________________________________ Credential No.:__________ Telephone: (_______)_____________________ Fax:_______________________ You must list 20 clock hours of continuing education which includes 10 hours in clinical content covering diag-nosis and treatment, 3 hours in social work ethics and 3 hours in clinical supervision.Ethics and clinical super-vision were to be completed between July 1, 2008 and June 30, 2010.Attach documentation verifying your attendance at the events.Please do not use initials when writing the names of the events or sponsoring organizations. Auditor Use Only Hours Month/Day/YearHours ApprovedNot Approved Event:________ ___________________________________________________________ ________________________ __________________________________________________ Presenter:________________________________________________________________________ SponsoringOrganization: ____________________________________________________________ ClinicalContent9 Ethics9 ClinicalSupervision9_________ _________ Event:_________________________________________________________ _______________ _________________________________________________ Presenter:________________________________________________________________________ SponsoringOrganization: ___________________________________________________________ ClinicalContent9 Ethics9 ClinicalSupervision9_________ _________ Event:_________________________________________________________ ________________ _________________________________________________ Presenter:________________________________________________________________________ SponsoringOrganization: ___________________________________________________________ Clinical Content9 Ethics9 ClinicalSupervision9→
Month/Day/Year Hours Event:___________________________________________________ _________________ ____________________________________________ Presenter: ______________________________________________________________________ Sponsoring Organization: ___________________________________________________________ ClinicalContent9 Ethics9Supervision Clinical9Event:______________________________________________ _________________ _______ ______________________________________________ Presenter: _______________________________________________________________________ Sponsoring Organization: __________________________________________________________ ClinicalContent9 Ethics9 ClinicalSupervision9Event:______________________________________________ _________________ _______ ______________________________________________ Presenter: _______________________________________________________________________ Sponsoring Organization: ____________________ ______________________________________ ClinicalContent9 Ethics9Supervision Clinical9Event:_______________________________________________ _________________ ______ _______________________________________________ Presenter: _______________________________________________________________________ Sponsoring Organization: ___________________________________________________________ ClinicalContent9 Ethics9 ClinicalSupervision9Event:______________________________________________________ _______________ _______________________________________________ Presenter: _______________________________________________________________________ Sponsoring Organization: __________________________________________________________ ClinicalContent9 Ethics9 ClinicalSupervision9Event:______________________________________________________ _______________ _______________________________________________ Presenter: _____________________________________________________________________ Sponsoring Organization: __________________________________________________________ ClinicalContent9 Ethics9 ClinicalSupervision9
Auditor Use Only Hours Approved NotApproved _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ __________
LICENSEE NAME_____________________________________ ADDRESS _____________________________________ _____________________________________ _____________________________________
*************************************************************************** AUDITOR USE ONLY: _____An Audit of this licensee’s continuing education report has been completed and the documentation has been found to be in compliance with all sections of Rule No. 317. _____An audit of this licensee’s continuing education report has been completed and has revealed that the documentation is not in compliance with Rule No. 317 for the following reason(s):_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Recommendation: _________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Reviewed by:_____________________________________________Date:_____________________________ ******************************************************************************************************Questions concerning your AUDIT should be directed to: ASWB AUDIT LOUISIANA-CE Box 1508 PO VA 22701 Culpepper, Phone:1-866-527-2384 Fax:1-540-829-0142 ContinuingEducation Requirements can be viewed on our websitewww.labswe.org. SeeRule No. 317 of theRules, Standards and Procedures.
