Activity Request

Activity Request

We need a few details about your activity to help us get started. All applications for CME credit must be submitted 6 months before the date of the activity. ( A continuing education offering shall be approved in increments of no less than 30 minutes.)
Name

First NameLast Name
Company
E-mail
example@example.com
Optional: Name of second person/staff you wish to receive e-mail notices about this program:

First NameLast Name
Optional: Second person/staff e-mail:
example@example.com
Phone Number

Area CodePhone Number
NOTICE: AS of March 16, 2026 we no longer provide credit to any program that has pharmaceutical/commercial support funding.
Has either you or the organization planning this activity directly received any pharmaceutical money for this program? NOT exhibitor fees.

YesNo
My program is 2 Months Away! Your program may be denied credit due to insignificant time.*

YesNo
Title of Activity - you CANNOT CHANGE this! *
We have a size limit on our LMS - No long titles - please.
Date of Activity*
How many speakers will you have? Please remember you will have to have a signed disclosure for EACH. Only speakers you want credit for!*
Lectures shorter than 30 minutes are not eligible for credit. All lectures should ideally be scheduled in 30-minute or one-hour sessions.

If any lectures will not offer CME credit, they must be clearly identified as non-credit sessions on the brochure.
How will this training change participants’ skills, strategies, performance, or patient outcomes?*
What outcomes would result from the changes? *
Do you have a way to measure these outcomes after the program, other than an evaluation?*
How many meeting planners will you have? Please remember you will have to have a signed disclosure for EVERYONE you list. MAX 10*
What is the purpose of this education?*
Based on your selections below we will form an agreement with costs.
Do you need Continuing Medical Education (CME) credit?

CME (Physician, Physician Assistant, Nurse Practitioner, Nursing Home Administrator) Cost $600.00 per 4 hour courseDentistry
Do you need Continuing Education (CE) credits? (Program content must pertain to credit selected.) (Fees start at $400.00 per 4 hour course)

Nursing (Kentucky Nursing)Respiratory (Kentucky)EMS (Kentucky)Certificate of AttendanceSonographer - Must have checked CME above
My program is 3 Months Away! If not do NOT choose any credits below.*

YesNo
STOP! Is your program 3 Months away? (Fees start at $400.00 per 4 hour course)

Community Health Worker (KY -Must have ALL paperwork three months in advance to apply)Social Work (After the initial $400 per 4 hour course a fee of $100 will apply)
Please READ CAREFULLY! Other credits that require specific or additional items:

Pharmacy (KY - Must have ALL slides for presentations three months in advance to apply) Must have all paperwork three months before your program and one of these dates: May 20, 2026, July 15, 2026, September 9, 2026, November 18, 2026 (These are the dates that the Pharmacy Board Meet and approve programs.) After the initial $400.00 per 4 hour course a fee of $70.00 will apply for this credit)
Activity Format (select all that apply)*

Live In-PersonLive Stream (Example Zoom)Enduring Material )Regularly Scheduled Series (grand round and tumor board) For Staff - must be same staff/audience every time .
How many hours of credit are you applying for? (Must be 30 minutes or more)*
Note: We DO NOT set up any Zoom presentations/conferences.
Would you like to have a Zoom meeting with us to go over your request?

NoYes
Any specific questions you want to go over when we contact you.
Should be Empty:

Activity Request

NOTICE: AS of March 16, 2026 we no longer provide credit to any program that has pharmaceutical/commercial support funding.