Free 49708.FH11 - Indiana

RECORD OF TRAINING
State Form 49708 (8-00) / FI 0005

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INSTRUCTIONS FOR SELF-DIRECTED TRAINING:

In order to document Category II credit hours for training, you may: 1. Complete Part A prior to training, and; 2. Have conference/workshop Trainer or Registrar complete Part B at the training site.

PART A

I hereby attest that I participated in the following training:
Contact hours Number of credit hours

Name of conference or workshop Location of conference or workshop Date(s) of conference or workshop

From:
Printed name of trainee

To:
Signature of trainee

PART B

Registration confirmed by:
Title Date (month, day, year)

Signature of conference/workshop Trainer or Registrar

INSTRUCTIONS FOR SELF-DIRECTED ACTIVITIES:

In order to document Category II credit hours for an activity, you may: 1. Complete Part C after completing the self-directed activity, and; 2. Obtain a signature confirming the activity, if applicable.

PART C
Name of activity Printed name of trainee Date(s) (month, day, year) Signature of trainee Contact hours

PART D
Signature

If applicable, completion of activity confirmed by:
Title Date (month, day, year)