Pay Later CEU Program Application

Midwifery Education Accreditation Council
Continuing Education Program Application
New! Please review the Cultural Compentency Section of MEAC's Guidelines Document in order to submit the application.
Please Review the Cultural Competency Guidelines*

Yes I have reviewed the Cultural Competency Guidelines

Sponsor Information
Main Contact Name:*

First NameLast Name
Sponsoring Organization/Agency:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail*
Do you have a co-sponsor?

YesNo
Co-Sponsor Name:

First NameLast Name
Co-Sponsor Organization/Agency:
Co-Sponsor Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Co-Sponsor Phone:

Area CodePhone Number
Co-Sponsor E-mail:

General Program Information
Program Title:*
Target Audience:
Is this program (check all that apply):*

in-persondistance educationavailable one time only (provide date and time below)available on multiple dates (provide dates and times below)available on-demand
Date for the first offering of the program:*
Location of Program, if offered in person:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Program Website URL:
Include this Program on MEAC's CEU Calendar of Events?

YesNo
For more information, registrants should contact:

First NameLast Name
E-mail
Number of contact hours you are seeking for the entire program:*
Number of individual sessions (subjects) to be reviewed for approval:*

Program Planning and Evaluation
How and why did you choose the subject for this program?
Upload the program brochure or flier*:*

Upload a File

Cancelof
The program brochure or flier may:
- Be in draft form
- Be a website (provide the URL below)
The program brochure should include:
- Name of the program
- Name of the sponsoring organization(s)
- Dates and schedule with allocation of expected session times
- Cost of attendance
- Names and credentials of presenters
- Topics presented
- Target audience
- Number of contact hours to be awarded
- Which organization(s)/agency(ies) have approved the program for continuing education credit (or are in the process of approving)
URL of brochure or flier, if different than program website address:
Upload the overall program evaluation form* that you supply to attendees:*

Upload a File

Cancelof
*Visit MEAC's website for a sample program evaluation form.
Additional comments about the program:

Program Attendance
How do you verify attendance at the program and its sessions?
How will your organization maintain program attendance records for the required 7-year period?
Name of person who will maintain program attendance records for the required 7-year period:

First NameLast Name
Where will your organization maintain program attendance records for the required 7-year period?
Upload the Contact Hour Attendance/Award Certificate* given to attendees:

Upload a File

Cancelof
Note that the Contact Hour Attendance/Award Certificate given to attendees must include:
- Name and Identification Number of the attendee
- The number of contact hours the attendee has been awarded
- The title and date of the program
- The MEAC contact hour identification number (supplied to you in your approval letter from MEAC)
- Last four numbers of participant’s social security number (XXXX SS#)
- Sponsor's name and contact information
- The words, "The Midwifery Education Accreditation Council approved this continuing education program. See www.meacschools.org for more information."
Visit MEAC's website for a sample Contact Hour Attendance/Award Certificate

Planning Committee
Note that the planning committee must include at least one CPM, LM, CNM, or CM.
List the name and credentials of each member of the planning committee:
Describe how a CPM, LM, CNM, or CM participated in planning session, content development, and evaluation of the program:

Session Information
For EACH session offered at this program, complete and submit a MEAC Continuing Education Session Application.

Your application can not be processed until all Session Applications have been received.
Name of session:*
List the name and credentials of each speaker/presenter for this session:
Upload a full-length resume or CV for each speaker/presenter in this session:*

Upload a File

Cancelof
Length of this session in minutes:*
Describe the teaching/delivery methods used in this session:
List 3 - 6 measurable behavioral objectives or learning objectives/outcomes for this session:" The student will be able to...."*
Outline the content for this session, including number of minutes for each topic:*
Describe how learning objectives/outcomes will be assessed in this session:
Is this session available via distance education?*

YesNo
Upload a sample pretest, if used in this session:

Upload a File

Cancelof
Upload a sample post-test for this session (required):*

Upload a File

Cancelof
Provide references or bibliography for this session (references should be in APA or similar format):*
Upload a sample of the Speaker/Session Evaluation form* used in this session:*

Upload a File

Cancelof
*Visit MEAC's website for a sample Speaker/Session Evaluation form
Do you offer additional sessions at this program?

YesNo
What is the total number of sessions you offer at this program?*
Complete the CEU Session Summary Table, ensuring that the title, name of speaker, and hours are completed for each session. Upload the completed Table here.*

Upload a File

Cancelof
Thank you. If you have supplied answers to all the required questions, you may now submit your application.
E-mail
Should be Empty:

Midwifery Education Accreditation Council

Continuing Education Program Application

Sponsor Information

General Program Information

Program Planning and Evaluation

Program Attendance

Planning Committee

Session Information