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CEA-OC Recertification Checklist (Please print this form and fill it out.)
___ I have included my $50.00 recertification fee. Make checks payable to CEA-OC.
I am completing my contact hours in the following way (check each option used):
___ CA BRN approved contact hours: I have _____ hours, specifics listed below.
___ Birth Observation(s): I have _____ hours, signed forms enclosed.
___ Childbirth Education Class Observation(s): I have _____ hours, signed forms enclosed.
___ Book or Film Review(s): I have _____ hours, typed review(s) enclosed.
___ Journal or Newsletter Article(s): I have _____ hours, typed articles enclosed.
Total contact hours: _________ (minimum total of 24 contact hours required)
Program Title:
Sponsor:
Date:
CA BRN Provider Number: Contact Hours:
Program Title:
Sponsor:
Date:
CA BRN Provider Number: Contact Hours:
Program Title:
Sponsor:
Date:
CA BRN Provider Number: Contact Hours:
Program Title:
Sponsor:
Date:
CA BRN Provider Number: Contact Hours:
Program Title:
Sponsor:
Date:
CA BRN Provider Number: Contact Hours:
Program Title:
Sponsor:
Date:
CA BRN Provider Number: Contact Hours:
Program Title:
Sponsor:
Date:
CA BRN Provider Number: Contact Hours:
___ I have included my $50.00 recertification fee. Make checks payable to CEA-OC.
I am completing my contact hours in the following way (check each option used):
___ CA BRN approved contact hours: I have _____ hours, specifics listed below.
___ Birth Observation(s): I have _____ hours, signed forms enclosed.
___ Childbirth Education Class Observation(s): I have _____ hours, signed forms enclosed.
___ Book or Film Review(s): I have _____ hours, typed review(s) enclosed.
___ Journal or Newsletter Article(s): I have _____ hours, typed articles enclosed.
Total contact hours: _________ (minimum total of 24 contact hours required)
Program Title:
Sponsor:
Date:
CA BRN Provider Number: Contact Hours:
Program Title:
Sponsor:
Date:
CA BRN Provider Number: Contact Hours:
Program Title:
Sponsor:
Date:
CA BRN Provider Number: Contact Hours:
Program Title:
Sponsor:
Date:
CA BRN Provider Number: Contact Hours:
Program Title:
Sponsor:
Date:
CA BRN Provider Number: Contact Hours:
Program Title:
Sponsor:
Date:
CA BRN Provider Number: Contact Hours:
Program Title:
Sponsor:
Date:
CA BRN Provider Number: Contact Hours: