Dear Presenter, thank you for taking the time to complete this form. The rest of the form will be completed by STAR NET. Please save a copy of this document for your records and email a completed copy of this document to your contact person so they can complete the remaining sections. Contact Hours: Click here to enter text. *
To Be Completed by Resource Specialist: Continuing Education Information
Early Intervention Hours for EI Providers Please submit this workshop for EI Credit Hour: * Post Date *
To Be Completed by Resource Specialist: Continuing Education Information (50-100 words)?
EI Principles (If submitting for Early Intervention Credit Hours): * To which of the following State Performance Plan indicators does this workshop relate? To which of the following State Performance Plan indicators does this workshop relate? To which of the following Professional Development Outcomes does this workshop relate? (Choose as many as apply) (Aligns with evaluations and Section 1 on the Approved PD Provider Activity Summary – ISBE Form 73-58) * Which of the following is the intended impact of the professional development activity? (Aligns with Annual Approved Provider Report – ISBE Form 73-59) Please choose one. ECPL Category * Choose all that apply (The more the merrier – These area search words). Always choose EC. * CDA Area for CDA Candidates. All contact hours spent on this area. Should this Workshop/Webinar be submitted to Gateways for Registry-approval? * To which of the following Gateways Content Area does this workshop relate? All contact hours spent on this area. Gateways Training Topic Areas (Please choose one.) Gateways Content Focus (Choose all that apply. STAR NET workshops will usually be PS, unless otherwise noted.) * Gateways CCDBG Health and Safety topic(s) this training addresses, if applicable (Choose one, if applicable): Gateways Training Type (Please choose one.) Is training single or multiple sessions? (Please choose one.) Workshop Fee: Free unless noted here. Workshops are held in the English language. Should this training appear on the Gateways Statewide Online Training Calendar? Workshop facility located in what County? * To be completed by STAR NET: Collaboration Information
(If this is in collaboration with the ECC, please use their collaboration form.
If the collaboration does not involve the ECC, please use this form.) Agency/Collaborator Information Agency/Program Name * Agency/Program Name Agency/Program Name Contact Person * Contact Person Contact Person Email Address column 1 * Email Address column 2 Email Address column 3 Phone column 1 * Phone column 2 Phone column 3 Fax Number column 1 * Fax Number column 2 * Fax Number column 3 * Secure and Payment of Location (AV requirements, location arrangement/set-up, guaranteed number shared with location) Other handouts (Such as regional information) Number of participants/agency Give-Aways for ea. participant AGENCY COLLABORATION WORKSHEET
Form is to be completed by ECC and shared with collaborating agency upon completion. All fields to be completed.
Workshop/Webinar Information Title: * Date(s): * Time(s): * Event ID#: * Workshop Location: * Location Phone Number: * Number of participants max: * Agency/Collaborator Information Presenter: * Cell #: * Email: * Consultant Fee: * Responsibilities Presenter Contact (Includes obtaining the following information: preferred room arrangement/set-up (e.g., rounds; 2 display tables along wall), agenda, required A/V, will presenter require sleeping room the night before, handout original to be copied) Location (Includes securing the following: A/V requirements with location or the person supplying, room arrangement/set-up requested, food order placed with location or outside caterer, guaranteed number shared with location) Secure Virtual Room (for webinars) Facilitator (provide lunch for presenter) Handouts (include all collaborators on the handout folders including the logo for each agency) Provide Required Paperwork to workshop (sign-in sheet, CPDU forms, evaluation forms, printed name tags) Payment Presenter Contract Presenter Travel Sharing cost * Location Invoice Sharing cost * Miscellaneous Expenses Sharing cost * Additional Notes STAR NET Staff should complete this form only if the workshop is a WBR. Is STAR NET taking registrations in Database?
(If taking registration in database participants’ name will appear on certificates, Registration forms will need to be distributed and submitted to star net.)
Is STAR NET Providing Sign in Sheet?
(If sign in sheet is provided, participants names will not appear on certificate and will not be entered into database)
Is STAR NET providing certificates?
(If certificates are provided, training will automatically be submitted for SLP credit and add to list to send for IDFPR credit.)
s STAR NET providing Evaluations?
If providing certificates is there a collaborator that needs to be listed on the certificate?
Number of participants: Will Breakfast or lunch be provided?
if you want to take door prizes and/or a give-a-way for each person in attendance, please indicate what you would like the support staff to gather for you:
Handouts should be to Dinnia 3 weeks prior to the workshop, which is: Do you want your handouts in folders?
Please indicate what other materials you want and if they should be in the folders or not. If nothing is checked in a row, then that item is not needed. Other Brochures/ Flyers/ Workshop Registration Forms/Materials (Please List)