The purpose of this sheet is to help you organize and record your documents. It is not a substitute for original documents.
Educator should document all completed activities that do not require preapproval of the LPDC on this form. Attach documentation to each completed sheet. LPDC will convert the contact hours to CEUs upon submission of the form. Complete additional sheets as needed. 

Name:  	     						Job Title:      
Educator ID:         		License Expiration Date:       			Date:       
Professional Development Activity	Date of Activity	Contact Hours	IPDP Goals	
			Which goal on your Individual Professional Development Plan does this activity support?	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
Total Contact Hours