{"id":50759,"date":"2018-12-19T12:53:41","date_gmt":"2018-12-19T17:53:41","guid":{"rendered":"https:\/\/health.uconn.edu\/human-resources\/services\/organization-and-staff-development\/professional-development\/inservicerequestform-2\/"},"modified":"2023-09-26T21:16:05","modified_gmt":"2023-09-27T01:16:05","slug":"ceuirequestform","status":"publish","type":"page","link":"https:\/\/health.uconn.edu\/human-resources\/services\/organization-and-staff-development\/professional-development\/ceuirequestform\/","title":{"rendered":"State of Connecticut CEUI Technical Course Seat Request"},"content":{"rendered":"<div id=\"pl-50759\"  class=\"panel-layout\" ><div id=\"pg-50759-0\"  class=\"panel-grid panel-no-style\" ><div id=\"pgc-50759-0-0\"  class=\"panel-grid-cell\" ><div id=\"panel-50759-0-0-0\" class=\"so-panel widget widget_black-studio-tinymce widget_black_studio_tinymce panel-first-child panel-last-child\" data-index=\"0\" ><div class=\"textwidget\"><h1>State of Connecticut CEUI Technical Course Seat Request Form<\/h1>\n<\/div><\/div><\/div><\/div><div id=\"pg-50759-1\"  class=\"panel-grid panel-no-style\" ><div id=\"pgc-50759-1-0\"  class=\"panel-grid-cell\" ><div id=\"panel-50759-1-0-0\" class=\"so-panel widget widget_black-studio-tinymce widget_black_studio_tinymce panel-first-child panel-last-child\" data-index=\"1\" ><div class=\"textwidget\"><h4>Fill out the form below to request a seat in a Fall 2023 State of Connecticut CEUI Technical course. The deadline to register is September 29.<\/h4>\n<\/div><\/div><\/div><\/div><div id=\"pg-50759-2\"  class=\"panel-grid panel-no-style\" ><div id=\"pgc-50759-2-0\"  class=\"panel-grid-cell\" ><div id=\"panel-50759-2-0-0\" class=\"so-panel widget widget_gform_widget gform_widget panel-first-child panel-last-child\" data-index=\"2\" ><script type=\"text\/javascript\">var 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gfield_visibility_visible\"  data-js-reload=\"field_34_2\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_34_2'>\n                            \n                            <span id='input_34_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_34_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_34_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_34_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_34_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_34_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_34_3\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_3\" ><label class='gfield_label gform-field-label' for='input_34_3'>UConn Health Email address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_34_3' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_34_4\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_4\" ><label class='gfield_label gform-field-label' for='input_34_4'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_34_4' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_34_4\"  \/><\/div><div class='gfield_description' id='gfield_description_34_4'>In case you need to be notified off work hours, please indicate an alternate number.<\/div><\/li><li id=\"field_34_34\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_34\" ><label class='gfield_label gform-field-label' for='input_34_34'>Date of Hire<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_34_34' type='text' value='' class='large'  aria-describedby=\"gfield_description_34_34\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_34_34'>Enter your date of birth as shown. CEUI requests your date of hire on your application.<\/div><\/li><li id=\"field_34_25\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_25\" ><label class='gfield_label gform-field-label' for='input_34_25'>Length of Service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_34_25' type='text' value='' class='large'  aria-describedby=\"gfield_description_34_25\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_34_25'>CEUI requests you enter your length of service. Please enter numbers only.<\/div><\/li><li id=\"field_34_35\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_35\" ><label class='gfield_label gform-field-label' for='input_34_35'>Course Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_34_35' type='text' value='' class='large'  aria-describedby=\"gfield_description_34_35\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_34_35'>Example: Welding II<\/div><\/li><li id=\"field_34_26\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_26\" ><label class='gfield_label gform-field-label' for='input_34_26'>Course Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_34_26' type='text' value='' class='large'  aria-describedby=\"gfield_description_34_26\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_34_26'>Example: AS15231<\/div><\/li><li id=\"field_34_29\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_29\" ><label class='gfield_label gform-field-label' for='input_34_29'>Course Fee<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_34_29' type='text' value='' class='large'  aria-describedby=\"gfield_description_34_29\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_34_29'>Enter the course fee as listed in the In-Service Catalog - eg. $285<\/div><\/li><li id=\"field_34_27\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_27\" ><label class='gfield_label gform-field-label' for='input_34_27'>Course Delivery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_34_27' class='large gfield_select'  aria-describedby=\"gfield_description_34_27\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Online - WebEx or other' >Online - WebEx or other<\/option><option value='Online - Self-Paced' >Online - Self-Paced<\/option><option value='On Campus' >On Campus<\/option><option value='Hybrid - Online and On Campus' >Hybrid - Online and On Campus<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_34_27'>Select how the course will be delivered.<\/div><\/li><li id=\"field_34_31\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_31\" ><label class='gfield_label gform-field-label' for='input_34_31'>Name of Community College Offering Course<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_31' id='input_34_31' class='large gfield_select'  aria-describedby=\"gfield_description_34_31\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Asnuntuck - AS' >Asnuntuck - AS<\/option><option value='Capital - CA' >Capital - CA<\/option><option value='Gateway - GW' >Gateway - GW<\/option><option value='Manchester - MA' >Manchester - MA<\/option><option value='Waterbury - NVCC' >Waterbury - NVCC<\/option><option value='Bristol - TXCC' >Bristol - TXCC<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_34_31'>Select the name of the community college from the dropdown<\/div><\/li><li id=\"field_34_36\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_36\" ><label class='gfield_label gform-field-label' for='input_34_36'>Room Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_34_36' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_34_37\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_37\" ><label class='gfield_label gform-field-label' for='input_34_37'>Instructor Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_34_37' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_34_38\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_38\" ><label class='gfield_label gform-field-label' for='input_34_38'>Course Duration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_34_38' type='text' value='' class='large'  aria-describedby=\"gfield_description_34_38\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_34_38'>Enter the number of days of the course.<\/div><\/li><li id=\"field_34_28\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_28\" ><label class='gfield_label gform-field-label' for='input_34_28'>Course Start Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_34_28' type='text' value='' class='large'  aria-describedby=\"gfield_description_34_28\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_34_28'>Enter the Course Start Date as listed in the In-Service catalog.<\/div><\/li><li id=\"field_34_39\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_39\" ><label class='gfield_label gform-field-label' for='input_34_39'>Course End Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_34_39' type='text' value='' class='large'  aria-describedby=\"gfield_description_34_39\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_34_39'>Enter the Course End Date. If this course is only one day, leave field blank.<\/div><\/li><li id=\"field_34_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_41\" ><label class='gfield_label gform-field-label' >Have you met the prerequisites for your selected course?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_34_41'>\n\t\t\t<li class='gchoice gchoice_34_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='Yes'  id='choice_34_41_0'    \/>\n\t\t\t\t<label for='choice_34_41_0' id='label_34_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_34_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='No'  id='choice_34_41_1'    \/>\n\t\t\t\t<label for='choice_34_41_1' id='label_34_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_34_41_2'>\n\t\t\t\t<input name='input_41' type='radio' value='No Prerequisite Required'  id='choice_34_41_2'    \/>\n\t\t\t\t<label for='choice_34_41_2' id='label_34_41_2' class='gform-field-label gform-field-label--type-inline'>No Prerequisite Required<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_34_15\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_15\" ><h2 class=\"gsection_title\">Manager\/Supervisor Notification<\/h2><div class='gsection_description' id='gfield_description_34_15'>Your manager\/supervisor will receive an email notification of this training request made by you. You must speak with your supervisor prior to submitting this form and confirm use of department or personal funds for payment, as well as accounting for time away from work to attend the course.<\/div><\/li><li id=\"field_34_8\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_8\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Manager\/Supervisor&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_34_8'>\n                            \n                            <span id='input_34_8_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.3' id='input_34_8_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_34_8_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_34_8_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.6' id='input_34_8_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_34_8_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_34_9\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_9\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Manager\/Supervisor&#039;s Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_34_9_container'>\n                                <span id='input_34_9_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_9' id='input_34_9' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_34_9' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_34_9_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_9_2' id='input_34_9_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_34_9_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_34_16\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_16\" ><h2 class=\"gsection_title\">In-Service CEUI Training Registration Agreement<\/h2><div class='gsection_description' id='gfield_description_34_16'>I certify I have discussed my application for State In-Service CEUI technical training with my manager\/supervisor. <\/div><\/li><li id=\"field_34_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_10\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >In-Service Training Registration Agreement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_34_10'><li class='gchoice gchoice_34_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Yes'  id='choice_34_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_34_10_1' id='label_34_10_1' class='gform-field-label 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