Form CDPH4488 "Genetic Counselor Licensure Continuing Education Declaration" - California

What Is Form CDPH4488?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2014;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDPH4488 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH4488 "Genetic Counselor Licensure Continuing Education Declaration" - California

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
Department of Public Health
Genetic Disease Screening Program
Submit by Email
Print Form
Genetic Disease Screening Program
Program Standards and Quality Assurance Branch
850 Marina Bay Parkway, F-175
Richmond, CA 94804
For questions, please call (510) 412-1479
Genetic Counselor Licensure Continuing Education Declaration
Name: ___________________________
License Number: _GC_________________
Expiration Date: ________________
This report should be submitted with your application for renewal of your Genetic Counselor License. Do not attach any supporting
documents to this declaration but maintain those documents in your personal files.
On the pages that follow, list all approved National Society of Genetic Counseling (NSGC) Category 1 continuing education units
(CEUs) and contact hours [Part 1], and all approved NSGC Category 2 CEUs and contact hours [Part 2] declared during your current
licensure period.
On this page, total all CEUs and contact hours declared. Check that you have a minimum of thirty (30) NSGC Category 1 CEU contact
hours, and a total of at least forty-five (45) CEU contact hours.
It is important to note that one NSGC CEU is equivalent to ten contact hours of continuing education. American Board of Genetic
Counseling Professional Activity Credits do not count towards the contact hours of continuing education required for license renewal.
CEUs
Contact Hours
Part 1 – Total (all pages) NSGC Category 1 CEUs
Part 2 – Total (all pages) NSGC Category 2 CEUs
Total CEUs Declared
I certify that the information I have provided on this declaration page is true and correct. I am aware that this declaration is subject to audit by
GDSP at its discretion.
Signature: __________________________________________
Date: _______________
Page: ______ of ______
Note: Each page must have a signed statement of truth and accuracy.
CDPH 4488 (ENG)(06/14)
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
Department of Public Health
Genetic Disease Screening Program
Submit by Email
Print Form
Genetic Disease Screening Program
Program Standards and Quality Assurance Branch
850 Marina Bay Parkway, F-175
Richmond, CA 94804
For questions, please call (510) 412-1479
Genetic Counselor Licensure Continuing Education Declaration
Name: ___________________________
License Number: _GC_________________
Expiration Date: ________________
This report should be submitted with your application for renewal of your Genetic Counselor License. Do not attach any supporting
documents to this declaration but maintain those documents in your personal files.
On the pages that follow, list all approved National Society of Genetic Counseling (NSGC) Category 1 continuing education units
(CEUs) and contact hours [Part 1], and all approved NSGC Category 2 CEUs and contact hours [Part 2] declared during your current
licensure period.
On this page, total all CEUs and contact hours declared. Check that you have a minimum of thirty (30) NSGC Category 1 CEU contact
hours, and a total of at least forty-five (45) CEU contact hours.
It is important to note that one NSGC CEU is equivalent to ten contact hours of continuing education. American Board of Genetic
Counseling Professional Activity Credits do not count towards the contact hours of continuing education required for license renewal.
CEUs
Contact Hours
Part 1 – Total (all pages) NSGC Category 1 CEUs
Part 2 – Total (all pages) NSGC Category 2 CEUs
Total CEUs Declared
I certify that the information I have provided on this declaration page is true and correct. I am aware that this declaration is subject to audit by
GDSP at its discretion.
Signature: __________________________________________
Date: _______________
Page: ______ of ______
Note: Each page must have a signed statement of truth and accuracy.
CDPH 4488 (ENG)(06/14)
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
Department of Public Health
Genetic Disease Screening Program
Name: ____________________________________________
Submit additional application if more space needed.
PART 1: CATEGORY 1 CEU DECLARATION
Check here
In the table below, list all approved Category 1 continuing education activities attended.
if more than 1
application is
being submitted.
Example:
1
1/02/2013
City General Hospital
New Topics in Genetic Counseling
0.8
8
Number of
Number of
No.
Program Date(s)
Sponsor of Program
Title of Program
CEUs
Contact
Earned
Hours
Total number of contact hours declared on this page:
I certify that the information I have provided on this declaration page is true and correct. I am aware that this declaration is subject to audit by
GDSP at its discretion.
Signature: __________________________________________
Date: _______________
Page: ______ of ______
Note: Each page must have a signed statement of truth and accuracy.
CDPH 4488 (ENG)(06/14)
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
Department of Public Health
Genetic Disease Screening Program
Name: ____________________________________________
Submit additional application if more space needed.
PART 2: CATEGORY 2 CEU DECLARATION
Check here
In the table below, list all approved Category 2 continuing education activities attended.
if more than 1
application is
being submitted.
Example:
1
1/02/2013
City General Hospital
New Topics in Genetic Counseling
0.8
8
Number of
Number of
No.
Program Date(s)
Sponsor of Program
Title of Program
CEUs
Contact
Earned
Hours
Total number of contact hours declared on this page:
I certify that the information I have provided on this declaration page is true and correct. I am aware that this declaration is subject to audit by
GDSP at its discretion.
Signature: __________________________________________
Date: _______________
Page: ______ of ______
Note: Each page must have a signed statement of truth and accuracy.
CDPH 4488 (ENG)(06/14)
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