CLEAR
CLEAR
85 East 7th Place, Suite 125, St. Paul, MN 55101-2143
FORM
FORM
Ph: 651-296-7938 • Fax: 651-282-2644 • boa.state.mn.us
CPE REPORTING FORM FOR STATUS CHANGE “ACTIVE”
Phone
Name
Certificate #
(First)
(M.I.) (Last)
(Suffix)
Y N
Group
QAS Self Study
Blended Learning
Nano Learning
Writing
Teaching
Technical
Nontechnical
Reg. Ethics
Behav. Ethics
Y N
Group
QAS Self Study
Blended Learning
Nano Learning
Writing
Teaching
Technical
Nontechnical
Reg. Ethics
Behav. Ethics
Y N
Group
QAS Self Study
Blended Learning
Nano Learning
Writing
Teaching
Technical
Nontechnical
Reg. Ethics
Behav. Ethics
Y N
Group
QAS Self Study
Blended Learning
Nano Learning
Writing
Teaching
Technical
Nontechnical
Reg. Ethics
Behav. Ethics
Y N
Group
QAS Self Study
Blended Learning
Nano Learning
Writing
Teaching
Technical
Nontechnical
Reg. Ethics
Behav. Ethics
Y N
Group
QAS Self Study
Blended Learning
Nano Learning
Writing
Teaching
Technical
Nontechnical
Reg. Ethics
Behav. Ethics
Y N
Group
QAS Self Study
Blended Learning
Nano Learning
Writing
Teaching
Technical
Nontechnical
Reg. Ethics
Behav. Ethics
Y N
Group
QAS Self Study
Blended Learning
Nano Learning
Writing
Teaching
Technical
Nontechnical
Reg. Ethics
Behav. Ethics
Y N
Group
QAS Self Study
Blended Learning
Nano Learning
Writing
Teaching
Technical
Nontechnical
Reg. Ethics
Behav. Ethics
Y N
Group
QAS Self Study
Blended Learning
Nano Learning
Writing
Teaching
Technical
Nontechnical
Reg. Ethics
Behav. Ethics
Y N
Group
QAS Self Study
Blended Learning
Nano Learning
Writing
Teaching
Technical
Nontechnical
Reg. Ethics
Behav. Ethics
Y N
Group
QAS Self Study
Blended Learning
Nano Learning
Writing
Teaching
Technical
Nontechnical
Reg. Ethics
Behav. Ethics
Y N
Group
QAS Self Study
Blended Learning
Nano Learning
Writing
Teaching
Technical
Nontechnical
Reg. Ethics
Behav. Ethics
Min. 120 hrs
*Delivery Method Options
**CPE Type Options
Min. 24 hrs
Group (whether Live or
Nano Learning (NL)
Technical
Min. 60 hrs
Internet-based) (G)
Writing (W)
Non-technical
Min. 8 hrs
Regulatory Ethics
QAS Self Study (S)
Teaching (T)
Behavioral Ethics
Blended Learning (B)
Independent Study (IS)
Min. 72 hrs
CPE Reporting for Status Change to Active FORM—Page 1 of 1
Rev 12/17