This form may be used to document professional development activities for which no contact hour certificate was issued. Please complete form as accurately and completely as possible and retain for your records.	
Title/Topic of Professional Development	     	
Date of Professional Development	     	
Start/End Times	     	
Hosting organization	     	
Name(s) of Presenters	     	
Goals & Objectives of Professional Development	     	
Contact hours Specify actual hours of engagement excluding lunch and breaks. Attach documentation if possible.	     	
Participant role	Check all that apply:
  Listening to presenters to acquire new information/knowledge
  Exploration of relevance and potential applications of workshop content to local situation 
  Interactive dialogue and questions with presenters and/or colleagues
  Participate in individual and group activities 
  Other – please specify       

My signature below attests to my participation in the PROFESSIONAL DEVELOPMENT described on this document. 
				
Participant Name (Print) 			Signature
				
			Date