Joint Provider Program Application
The APA Joint Provider Program partners with non-accredited organizations to jointly provide AMA PRA Category 1 Credit™ for quality continuing medical education (CME) activities. Please complete and submit this application to join the Joint Provider Program.
BASIC INFORMATION
Your name and title
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Email Address
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Please provide the name and email of the primary CE liaison for your organization. This would be a designated point of contact that is responsible for submitting all activity applications and participating in the planning, implementation, and evaluation of any jointly provided CE activity to ensure ACCME standards are met. This person will also be sent Joint Provider Program updates via email communications and/or webinars as needed.
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First Name
Last Name
Email Address
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Name of your organization
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Are you an APA District Branch (DB)?
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Yes
No
District Branch Name
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you affiliated with the APA?
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Yes
No
Explain your APA affiliation
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**Please note that all external organizations are subject to a one time non refundable application fee of $500 upon approval to join the Joint Provider Program
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CME Activity Information
Do your CME activities relate to psychiatry, mental health, or neurology?
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Yes
No
Please state the goals or mission of your program/organization
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Do you receive educational support for your CME activities?
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Yes
No
Identify the funding source(s):
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Pharmaceutical company
Medical device company
Non-commercial grant (hospital, insurance company)
Non-profit organization
Do you provide exhibits or advertisement opportunities at your live events?
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Yes
No
Do you need CME for activities that will be
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Live
Online
Both
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CME History
Has your organization provided CME in the past?
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Yes
No
Were you an accredited CME provider?
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Yes
No
Have you received joint sponsorship elsewhere? (Yes/No Option)
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Yes
No
Who sponsored your CME programs?
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How many CME activities are planned for this year?
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Please Select
1-2
3-4
5-6
Over 7
How many will be live activities?
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How many will be online activities?
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CME Administration & Governance
Do you have a CME planning or education committee?
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Yes
No
What is the structure of your CME committee?
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How often does the committee meet?
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List the name, title, and term of the person chiefly responsible for the CME program and the person responsible for administrative support
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Describe your organization’s governance structure and relationship to the CME Program Committee
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Professional Practice Gap & Needs Assessment
How does your organization determine professional practice gaps?
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Who is the prospective target audience for your CME activities?
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How do you determine whether activities are based on identified needs?
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Needs Survey
Evaluation data from previous programs
Consensus of experts
Literature searches
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Management of Conflict of Interest (MOCI)
Is this your organization's first application for CME?
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Yes
No
In past CME activities, explain if and how you provided disclosures to participants and who disclosed
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Describe the MOCI process used to ensure CME activity unbiasedness
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Evaluation & Measurement of Outcomes
How do you collect participant data and determine their physician/non-physician status?
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What strategies and measures are used to evaluate the activity’s impact?
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How will the evaluation findings be utilized?
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Upload Organizational Chart
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Upload Onsite Handouts/Syllabus
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Upload Promotional/Marketing Materials
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