CEU Reporting Form is on page 2 and 3 please scroll down.

To return form by e-mail you must follow these instructions for it to be accepted:
1. Address the e-mail to professionalpractice@cmto.com
2. In the subject line write CEU Reporting form for [your registration number]
3. In the body of the e-mail you must put the following statement:
I confirm with this e-mail that I, [your name that appears on the Register],
completed the attached CEU Reporting Form myself. All information contained
on the form is accurate and true.
[your name]
[your registration number]
4. The e-mail address that you send from must match the e-mail address that we
have on file for you.
Please note that signing or issuing, in your professional capacity, a document
that you know contains a false or misleading statement is a professional
misconduct.

CEU Reporting Form

I hereby certify that I have read the CEU articles in The College Standard and have
completed the required responses to the CEU questions.
Name: Jocelyn Sommerville
Number ___________

Registration

Category A Activities
Activit
y
Code
AAW

Competency /
Modality Code

Number of
CEUs

Description

CTE

AAW

MMR

AWR

CCR

APE

MPN

Massage Techniques Attended a three hour

workshop on November 1st, 2014. It was
informative about advanced myofasical
techniques.
Myofascial Release - Performed a three hour
workshop on November 15th, 2014 iwith a
focus on myofascial release techniques.
Client Relations Reviewed books and articles
such as Global Portfolio and Client
Relationship Management published by Wiley.
The outcome of learning that was achieved
was how to interact cooperatively with
patients by acknowledging and respecting the
value and beliefs of others.
Sandy Chen provided assistance during
treatment in the clinic. We discussed
appropriate methods and techniques for the
patient with sore back and neck pain.

Total Category A CEUs (minimum 20 required)

17

(copy this amount to page 2)

CEU Reporting Form

Category B Activities
Activity
Code
APW

Modality
Code
MPL

Number of
CEUs
5

AWR

MKN

APE

MYO

Description
Remedial Exercise and Pilates Presented a
three hour workshop to students in the
community about how to generate a proper
exercise program.
Performed research studies about kinesiology
from the book, Applied Kinesiology published
by North Atlantic Books. Research reviewed
mechanics and mechanisms of the human
body.
Yoga and Remedial Exercises Given to
patients that needed an additional stimulus
throughout the week that would provoke
relaxation.

Total Category B CEUs

13
Total Category A CEUs 17
Total Category A and B CEUs (minimum 30 required)

30

I hereby certify that the information on this form is accurate and true.
________________________________________________
Signed this ___1___ day of ________December_________, 2014__ at __Humber
College________________.
day
month
city