Form 5 - Request For Cle Credit For Publication Of A Book Or Article Page 2

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12. Does any portion of the material relate to professionalism (Creed of
Professionalism)?
Yes _______
No __________
If yes, what percentage? ________%
13. Does any portion of the material relate to substance abuse (causes, detection,
prevention and treatment)?
Yes _______
No __________
If yes, what percentage? ________%
14. Does the book or article consist of repetition or re-working of material for which the
applicant has previously received CLE credit in Ohio? If yes, explain:
_____________________________________________________________________
Yes _______
No __________
15. How many hours did the applicant spend engaged in this research? __________
16. I hereby request _________ CLE credit hours for the previously described book or
article. (A maximum of 10 hours credit may be granted per biennium).
Date: ___________ Author's Signature: ___________________________________
Attach a copy of the book or article. It will be returned once a determination has been
made. NOTE: Credit will not be given for preparation of meeting, seminar or
conference materials. The material submitted must have been PUBLISHED.
FORM 5 MUST BE SUBMITTED TO THE CCLE WITHIN NINETY (90) DAYS OF
PUBLICATION OR BY THE END OF THE AUTHOR'S BIENNIAL REPORTING
PERIOD, WHICHEVER IS LATER.
===============================================================
CCLE OFFICE USE ONLY:
Activity No: 8000-_____________
Approved: ______________________
General ______ Ethics ______ Substance Abuse ______ Professionalism ______
Denied: _____________________________________________ Date: ________
Rev. 12/04
===============================================================

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