Please note, contact Hour Approval is granted for two years, and will expire two years from the approval date.
Approval Request Information
Original Approval Request:* Yes No Invalid Input
Renewal Approval Request:* Yes No Invalid Input
Previous IAHCSMM Approval Code:Invalid Input
Program Overview
Delivery Method
Method of Delivery (you may choose multiple methods ):Lecture / Conference Print / Online Publications Chapter Meeting Online Activity Webinar Vendor In-Service Invalid Input
Faculty (Please list each speaker, topic, objective and length of time. Clear objectives and time allocation for each topic must be submitted. A minimum of 1 speaker, topics, objective and length of time must be listed prior to submitting the request.)
Speaker 1:
Name/Title:* Invalid Input
Topic:* Invalid Input
Objectives:* Invalid Input
Presentation Duration:* Invalid Input
Speaker 2:
Name/Title:Invalid Input
Topic:Invalid Input
Objectives:Invalid Input
Presentation Duration:Invalid Input
Speaker 3:
Name/Title:Invalid Input
Topic:Invalid Input
Objectives:Invalid Input
Presentation Duration:Invalid Input
Speaker 4:
Name/Title:Invalid Input
Topic:Invalid Input
Objectives:Invalid Input
Presentation Duration:Invalid Input
Additional Information:Invalid Input
Contact Information - All fields are mandatory
Name/Title:* Invalid Input
Telephone 555-555-5555 :* Invalid Input
Email:* Invalid Input
Address:* Invalid Input
City:* Invalid Input
State/Province:* Invalid Input
Zip/Postal:* Invalid Input
Supporting Documents Submission Requirements: (1) Lectures and Conferences: also include a sample brochure and/or handout, clearly outlining the program title(s), objectives, and the number of contact hours planned for each topic; (2) Print and Online Publications: include a copy of the article or module including the post test, if applicable; and (3) Presentation and In-Services: include a copy of the handout, outline, or PowerPoint presentation (in PDF format) that will be used, including the post test, if applicable.
File #1:Invalid Input
File #2:Invalid Input
File #3:Invalid Input
File #4:Invalid Input
We remind you that if your submission should have supporting documents, failure to upload them here may cause a delay in the approval process.
