Community Member CEU Request Form

Community Member CEU Request Form

It is the responsibility of the community member to retain a record of their clock hour request.
Please submit a separate request for each course taken (unless submitting a college transcript).
RPS District staff should NOT use this form. Please follow the process on the RPS staff intranet.

First and Last Name*

Email Address*

Folder Number

Title of Activity*

Date of Activity*

Description of Activity*

Activity Format*

College Course

Workshop, Conference, Institute or Seminar

Staff Development Activity or Inservice

Curriculum Development

Peer Coaching/Mentorship Relationship

Professional Service

Leadership Experience

Understanding of Diverse Education Setting

Travel or Work Experience

Online Activity

Category*

CEU for Hours

Cultural Competency

Positive behavior intervention strategies (PBIS)

Reading preparation related to instruction

Mental health training

Suicide prevention training

ELL - English language learners

Administrative

Accommodations, Modifications, and Adaptations of Curriculum, Materials and Instruction

American Indian History and Culture

Cultural Competency Focus

Racial, Cultural, and Socioeconomic Groups

American Indian and Alaskan Native Students

Religion

Systemic Racism

Gender Identity, Including Transgender Students

Sexual Orientation

Language Diversity

Individuals with Disabilities and Mental Health Concerns

CEU Hours

For the CEUs, please enter the total hours in the first box, then the number of hours in each category below. The sum of all categories must equal the total number of CEU hours requested.

Total CEU Hours*

Total CEU hours for Cultural Competency: Racial, Cultural, Socio-Economic

Total CEU hours for Cultural Competency: American Indian and Alaskan

Total CEU hours for Cultural Competency: Religious Diversity

Total CEU hours for Cultural Competency: Systemic Racism

Total CEU hours for Cultural Competency: Language Diversity

Total CEU hours for Cultural Competency: Individuals with Disabilities

Total CEU hours for Cultural Competency: Gender Identity

Total CEUs for Cultural Competency: Sexual Orientation

Total CEUs for Positive Behavior Intervention Strategies (PBIS)

Total CEUs for Reading Preparation Related to Instruction

Total CEUs for Mental Health Training

Total CEUs for Suicide Prevention tTraining

Total CEUs for ELL - English Language Learners

Total CEUs for Administrative

License Expiration Date*

Upload CEU Certificate

Please upload a PDF of the CEU Certificate*

Drag and drop files here or

Send me a copy of my responses

Powered by

Privacy Notice|Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.