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.
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
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!*
How many meeting planners will you have? Please remember you will have to have a signed disclosure for EVERYONE you list. MAX 10*
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)Dentistry
Do you need Continuing Education (CE) credits? (Program content must pertain to credit selected.) Extra Fees will apply.

Nursing (Kentucky Nursing)Respiratory (Kentucky)Occupational Therapy (Kentucky)EMS (Kentucky)Certificate of Attendance
STOP! Is your program 2 1/2-3 Months away? Extra fees may will apply

Yes, my program is 2 1/2 to 3 months away.Social Work (Kentucky Must have ALL Paperwork two months in advance to apply)Professional Counselors (KY - Must have ALL paperwork two months in advance to apply)Licensed Alcohol and Drug Counselors (KY - Must have ALL paperwork two months in advance to apply)Community Health Worker (KY -Must have ALL paperwork two months in advance to apply)
Please READ CAREFULLY! Other credits that require specific or additional items:

Radiology (Kentucky) Must have lectures that target Radiology - objectives must include Radiology component. Must have ALL slides for presentations two months in advance to applyPharmacy (KY - Must have ALL slides for presentations two months in advance to apply)Physical Therapy (3 hours or less will only be approved for Category 2 credit.)Sonographer - Must have checked CME aboveDietitian (Kentucky) MUST have a dietitian on the planning committee - CDR credentialed RD or DTR, and provide their registration number.
Activity Format (select all that apply)*

Live In-PersonLive Stream (Example Zoom)Enduring Material (Pre-recorded VIDEO- all enduring materials will be hosted on the AHEC's Learning Management System) Additional charge will apply for course build.Regularly Scheduled Series (grand round and tumor board) For Staff - must be same staff/audience every time .
Enduring Materials ONLY Pre-Recorded Video to be taken as a course later- will require 10 questions and answers for a quiz - additional course build fee will be charged:

Private Video Course: My course should be listed as a private course so that only my audience can accessPublic Video Course: Will be free to the public, will be listed on the AHEC's learning site for anyone to access.Does not apply
How many hours of credit are you applying for?*
Has either you or the organization planning this activity directly received any pharmaceutical money for this program? NOT exhibitor fees.

YesNo
If yes, you have pharmaceutical money please list the COMPANY NAME your contract is with.
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: