Form WC4.1 "Continuing Education Course Submission Form" - Montana

What Is Form WC4.1?

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

Form Details:

  • Released on November 3, 2009;
  • The latest edition provided by the Montana Department of Labor and Industry;
  • 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 printable version of Form WC4.1 by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

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Download Form WC4.1 "Continuing Education Course Submission Form" - Montana

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MONTANA DEPARTMENT OF LABOR & INDUSTRY / EMPLOYMENT RELATIONS DIVISION
CONTINUING EDUCATION COURSE SUBMISSION FORM
Complete a form and attach required materials for each course submitted for review.
Sponsoring Organization
Mailing Address
Phone Number (including area code)
Course Title
Proposed date(s) of offering
Designated contact person for this course
Phone #
Method of instruction: (check only one)
Attach the following material to each submission:
____ the course goals and objectives
classroom settings or seminars
____ a syllabus or course outline, including a
self-study
summary of each course topic
electronic media
____ method of administering examinations (if any)
correspondence
____ a written explanation of test security measures (if any)
teleconference
____ method of attendance verification
____ method of student record maintenance
computer-based training
____ a list of other states that have approved the course and the
(specify)
credits granted the course in those states (if any)
remote training
____ a list of instructors
Course length in hours ________________
I request that the Department of Labor & Industry / Employment Relations Division review the attached materials
for certification and approval of continuing education credits. I certify that the information submitted regarding
this course is true and correct. I understand that the Department of Labor & Industry / Employment Relations
Division may request additional materials. I certify instructor qualifications, ARM 24.29.811-24.29.851,
including the practical and academic experience as part of the course review and certification process of each
faculty member is sufficient to teach the subject assigned; the course enhances the ability of a Workers
Compensation Claims Examiner to provide services to the public effectively; and the subject matter relates to
professional ethics, where practicable.
____________________ _____________________________ __________________________ _________________
Name (please print)
Signature
Title
Date
For Department Use
Course #_______________________________
Date Approved ____________________________
Credit Hours Approved __________________
Date Disapproved ___________________________
___________________________________________
Signature
WC 4.1 Con. Ed. Course Submission Form Revised 11/3/2009
MONTANA DEPARTMENT OF LABOR & INDUSTRY / EMPLOYMENT RELATIONS DIVISION
CONTINUING EDUCATION COURSE SUBMISSION FORM
Complete a form and attach required materials for each course submitted for review.
Sponsoring Organization
Mailing Address
Phone Number (including area code)
Course Title
Proposed date(s) of offering
Designated contact person for this course
Phone #
Method of instruction: (check only one)
Attach the following material to each submission:
____ the course goals and objectives
classroom settings or seminars
____ a syllabus or course outline, including a
self-study
summary of each course topic
electronic media
____ method of administering examinations (if any)
correspondence
____ a written explanation of test security measures (if any)
teleconference
____ method of attendance verification
____ method of student record maintenance
computer-based training
____ a list of other states that have approved the course and the
(specify)
credits granted the course in those states (if any)
remote training
____ a list of instructors
Course length in hours ________________
I request that the Department of Labor & Industry / Employment Relations Division review the attached materials
for certification and approval of continuing education credits. I certify that the information submitted regarding
this course is true and correct. I understand that the Department of Labor & Industry / Employment Relations
Division may request additional materials. I certify instructor qualifications, ARM 24.29.811-24.29.851,
including the practical and academic experience as part of the course review and certification process of each
faculty member is sufficient to teach the subject assigned; the course enhances the ability of a Workers
Compensation Claims Examiner to provide services to the public effectively; and the subject matter relates to
professional ethics, where practicable.
____________________ _____________________________ __________________________ _________________
Name (please print)
Signature
Title
Date
For Department Use
Course #_______________________________
Date Approved ____________________________
Credit Hours Approved __________________
Date Disapproved ___________________________
___________________________________________
Signature
WC 4.1 Con. Ed. Course Submission Form Revised 11/3/2009
SUBMISSION REQUIREMENTS
Course Submissions
Requests for approval of courses must be received no less than 30 days prior to the starting date of
the course.
Fees
There is a course submission fee of $75.00 for each course. Submission must be preceded or
accompanied by any required fee for initial course review to be conducted by the Certification
Program. Courses approved are valid for two (2) years from the date of approval.
Send the course submission and fees to:
Montana Department of Labor & Industry/Employment Relations Division
C/O Examiner Certification Program
P.O. Box 8011
Helena, Montana 59604-8011
Student Protection Policies
All student fees and fee refund policies must be disclosed to students before enrollment. If a
course is canceled for any reason, all charges are refundable in full within 45 days, unless the
refund policy is clearly defined in the enrollment application.
Each student who successfully completes a course must receive proof of course completion,
including the Certification Program-assigned course approval number, from the sponsoring
organization.
Our web site address is:
http://erd.dli.mt.gov/examinercertification
WC 4.2 - Cont. Ed Course Submission Form Revised 11/3/09
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