CME Planning Form
Special Event - One Time Program
Program Planner Name
*
First Name
Last Name
Degree
Planner Email
*
example@example.com
Program Planner CV/Resume
*
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Title of Presentation
*
Date of Program
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Length of Program
*
Please Select
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
6.5
7.0
7.5
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1. Speaker Name
*
First Name
Last Name
1. Speaker Email
*
example@example.com
2. Speaker Name
First Name
Last Name
2. Speaker Email
example@example.com
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Continuing Medical Education programs are structured events improving the knowledge and performance of physicians. Is your program audience mainly physician participants?
Please Select
Yes
No
Program Format
*
Please Select
Live In Person
Live via Zoom
Will any of the time allotted for this program include non-educational time?
*
Please Select
Yes
No
Will this activity be supported in any way by commercial interest? This includes provision of meals, speaker fees, etc?
*
Please Select
Yes
No
If yes, please describe commercial interest (name, support, etc).
What practice-based gap will this program address?
*
List Three Program Expectations
*
What change in strategy, performance or patient care would you like this program to help learners accomplish?
*
Patient Care and/or Procedural Skill
Medical Knowledge
Practice Based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Provide Patient-Centered Care
Work in Interdisciplinary Teams
How will learners document their expected changes in strategy, performance or patient care post program?
*
Please Select
Survey/Evaluation with mandatory "two" new insights or concepts from program
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