CE Roster Correction Form

Roster corrections are due 45 days after receipt of the course roster. Use the form below to submit any changes (adding participants, deleting participants and changing the CEU amount for participants).

* indicates required field.

Provider Name:

Four-Letter Provider Code:*

CE Administrator's First Name:*

CE Administrator's Last Name:*

CE Administrator's E-mail:*

Course Number:*

Course Title:*

Offering Number:*

My CE Provider Manager is:*

Please include this information for each roster correction in the box below:

  • Correction – Either Add, Delete, or Change CEU Amount
  • Participant's Name
  • ASHA Number
  • Full street address
  • If you are adding a participant also include their phone number & e-mail address
  • Amount of CEUs

Example: [ADD] [Last name, first name] [12345678] [2200 Research Blvd, Rockville, MD 20850] [CEUs]

Roster Corrections:*

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