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
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please complete if you have a second planner....
Program Planner Name
First Name
Last Name
Degree
Planner Email
example@example.com
Program Planner CV/Resume
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Title of Presentation
*
Date of Program
*
-
Month
-
Day
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
Program Coordinator For Event
*
First Name
Last Name
Program Coordinator Email
*
example@example.com
Back
Next
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
3. Speaker Name
First Name
Last Name
3. Speaker Email
example@example.com
4. Speaker Name
First Name
Last Name
4. Speaker Email
example@example.com
5. Speaker Name
First Name
Last Name
5. Speaker Email
example@example.com
6. Speaker Name
First Name
Last Name
6. Speaker Email
example@example.com
Back
Next
Program Format
*
Please Select
Live In Person
Live via Zoom
Hybrid (in person/zoom options)
Are you recording this event for an internet enduring program?
*
Please Select
Yes
No
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?
*
Please Select
Yes
No
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
Submit
Should be Empty: