Regular Scheduled Series
Initial Application
Program Director Name
*
First Name
Last Name
Degree
Program Director Email
*
example@example.com
Program Planner CV/Resume
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Program Coordinator
*
First Name
Last Name
Program Coordinator Email
*
example@example.com
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Title of Regular Scheduled Series
*
Dates of Programs from 09/01/2025 - 12/31/2026: (must be in mm/dd/year format)
*
Length of Program
*
Please Select
0.5
1.0
1.5
2.0
2.5
3.0
Program Format
*
Please Select
Live In Person
Live via Zoom
Hybrid (in person/zoom options)
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
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