Continuing Education Verification Form

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Continuing Education Verification Form

Email *

Name:
*

Nursing Credentials:
*

Email Address:
*

Date:
*

YYYY

Instructions

*Complete the following form with information on continuing education programs you have completed in the past five years. These programs must be relevant to examination, care and treatment of the foot and lower extremity. This can include foot care, wound care, dermatology, neurology, physical examination, diabetic foot problems, common foot problems and deformities, etc. You can also include programs about infection control, instrument care and disinfection, patient education, shoes and orthopedic braces.

**You will need a total of at least 25 CE or CME credits to satisfy the prerequisite for the CFCS certification.

Continuing Education Verification Form

LIST YOUR CE PROGRAMS TAKEN BELOW:

PROGRAM DATE TITLE OF COURSE COURSE PROVIDER CE Credits

Example:

6/10/2024 Diabetic Foot Care Madison Hospital 2.0 hrs

Total Credit Hours (minimum = 25 hours) *

Nurse Signature

(Typing your name below constitutes a legal signature and verifies that all information provided in this form is true and correct)

Date: *

YYYY

A copy of your responses will be emailed to the address you provided.

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