Continuing Education for Respiratory Therapists (CERT) Application

The TSRC is recognized by the Texas Medical Board as a source of approval of Continuing Education for Respiratory Therapists (CERT) program offerings for Respiratory Care Practitioners in the state of Texas. To apply for approval of your CERT program, complete the following online Approval Application to us. All applications are reviewed for content and relevance to the field of Respiratory Care. Please feel free to contact us with any questions concerning the CERT Application process.

Please review the Program Approval Application Instructions prior to beginning the submissions process or download the instructions.

You will need to either download or complete a “Form A” for each presentation / presenter for your program to be submitted with your program approval application.

Please submit any questions to TSRC President-Elect: president-elect@tsrc.org; Vice-President: vice-president@tsrc.org or Treasurer: treasurer@tsrc.org

"*" indicates required fields

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Region of Event*

Select what region the event will be held.

Contact Person*

First Last

Enter the name of the person who will be coordinating the event.

Contact Email*

Enter Email Confirm Email

Contact Phone Number

Program Title*

List the specific program title.

Start Date*

MM slash DD slash YYYY

List the start date of the original event.

Start Time*

Hours

Minutes

AM/PM

End Date*

MM slash DD slash YYYY

Enter the end date of the first subsequent offering.

End Time*

Hours

Minutes

AM/PM

Start Date – 1st subsequent offering

MM slash DD slash YYYY

List the start date of the first subsequent offering.

End Date – 1st subsequent offering

MM slash DD slash YYYY

Start Date – 2nd subsequent offering

MM slash DD slash YYYY

List the start date of the first subsequent offering.

End Date – 2nd subsequent offering

MM slash DD slash YYYY

Start Date – 3rd subsequent offering

MM slash DD slash YYYY

List the start date of the first subsequent offering.

End Date – 3rd subsequent offering

MM slash DD slash YYYY

Start Date – 4th subsequent offering

MM slash DD slash YYYY

List the start date of the first subsequent offering.

End Date – 4th subsequent offering

MM slash DD slash YYYY

Please enter any additional dates in which the course would be offered.

Program Location*

Name of the facility the event will take place.

Program Address*

Street Address Address Line 2 City State ZIP Code

Is this event sponsored?*

Yes

Please identify if an organization or company is sponsoring this event.

Will vendor space be provided?*

Yes

Max Number of vendor spaces*

Please enter a number less than or equal to 40.

Total Number of CERT hours requested. Max 20*

One CERT hour is equal to 60 minutes of instructional contact time. Instructional contact time does not include registration, break or evaluation periods. We will round the time to the nearest hour. Calculate the total number of CERT hours you are requesting by adding up the number of instructional contact hours. This does not include registration periods, introduction (unless instructional, with objectives), breaks, meals, social activities, and evaluation activities.

Please enter a number less than or equal to 30.

Has the information contained in the program been given before in the last 24 months.*

Yes

Can participants receive partial credit for partial attendance?*

Yes

Upload Forms

Upload forms may be in Adobe (PDF) or Word document (docx) format only.

I will*

upload Form “A”

complete online.

Upload Form A*

Drop files here or

Accepted file types: pdf, docx, Max. file size: 64 MB, Max. files: 30.

Please scan “Form A”s for this program to upload.

Complete Form “A” for each presentation / presenter for your program. Clicking here will open a new tab.

Attach Program Brochure / Agenda

Accepted file types: pdf, docx, Max. file size: 64 MB.

Brochure / Agenda information should match that on each “Form A.”

Attach Sample Evaluation

Max. file size: 64 MB.

A Program Evaluation is required to be filled out by all attendees. Please attach a sample fo the program evaluation you plan to use.

Facility Contract

Max. file size: 64 MB.

If your location requires a contract to be signed, please submit it to be reviewed.

Catering Contract

Max. file size: 64 MB.

If your program requires a contract for catering, please uploaded to be reviewed.

Hotel Block Contract

Max. file size: 64 MB.

If you are requesting a hotel block contract, please submit it to be reviewed.

Pricing/Payment

The following information will determine the charges.

$40 Late Fee.

The event is within the next 30 days.

The event is over 30 days from now.

There is a $40 fee for CEU events scheduled less than 30 days ahead of time.

Is the program non profit or for profit? (Select one)*

The sponsor is a non-profit organization.

The sponsor is a for-profit organization.

Non-Profit CEU's

CEU’s offered by Non-Profit Organizations

For-Profit CEU's

CEU credits offered by For-Profit organizations

Non-Profit CEU's over 12 Quantity

Price: $12.00

Quantity

Each CEU hour over 12 is $12

For-Profit CEU's over 12 Quantity

Price: $20.00

Quantity

Each CEU hour over 12 is $20

Subsequent/Repeat Dates (NP) Quantity

Price: $12.00

Quantity

$12 for each Subsequent/Repeat date that the CEU’s are offered.

Subsequent/Repeat Dates (FP) Quantity

Price: $20.00

Quantity

$20 for each Subsequent/Repeat date that the CEU’s are offered.

Total

Payment choice*

Check Payment Information

Thank you for choosing to pay by check. Check payments must be mailed to 2025 Guadalupe St., Ste. 260, Austin, TX 78705-5642 include on memo line: the dates or title of program, and must be received before the program can be reviewed for approval.

Thank you for your application. Applications will not be considered until form A, the agenda/brochure, the evaluation form, and the payment are received.

Credit Card

Card Details

Cardholder Name

This field is for validation purposes and should be left unchanged.