Appendix 3

OLA WORKSHOP/PROGRAM PLANNING FORM

Instructions: Complete (type or print only) and submit at least 10 weeks prior to date of program both to:

(For full instructions on completing a section, click on its hyperlink.)

1. Division/Roundtable/Committee Sponsor(s): 
   
   
2. Program Contact Person: 
   
   
3. Address: 
   
   
4. Telephone: (W)                                                  (H)
   
   
5. Program Title: 
   
   
6. Date of Program: 
   
             Time: 
   
             Location (city, facility and room): 
   
   
7. Number of Instructional Hours:
   
   
8. Number of Participants Expected: 
   
   
9. Target Group: 
   
             Level of Expertise (basic, intermediate or advanced): 
   
   
10. Charge to Each Participant: 
    
    
11. Reason for Offering Workshop (based on needs assessment survey, perceived need, survey, etc.)
    
    
    
    
    
    
12. Goal/Purpose of the Program: 
    
    
    
    
    
13. Learning Objectives: (At the end of the program, participants will be able to …) 
    
    
    
    
14. Subject Matter and methods to be Used:
    Attach an outline that includes specific times, topics and methods.
    
    
15. Instructional Staff: (names and rationale for choices)
    
    
    
    
    
    
16. Evaluation:
    Attach a copy of your evaluation and/or describe the process you plan to use.
    
    
17. Proposed Budget:
    Attach the Oklahoma Library Association Workshop Request Form.
    
    
18. Publicity:
    Attach a copy of the flyer and news release to be used.
    List the publications to which publicity will be sent:
    
    
19. CE Consultant Verification Statement: I confirm that I, or my representative, have attended planning meetings for the workshop/program and that the OLA guidelines for the workshop/program planning have been followed.
    
    Signature of CE Consultant:_________________________________
    
    
20. Signature of Contact Person:_________________________________
    
    
21. Date of Application: 
    

    OLA Executive Board Recommendation:		Certification Specialist Recommendation:
    (circle one)	Approved  Pending  Disapproved	(circle one)	Approved Pending  Disapproved

    Date_________________	Date_________________
    ______________________________ Signature of Executive Director	______________________________ Signature of Certification Specialist