Application for CPD
For: Events requiring a CPD assessment and allocation
Section 1: Event Overview
1. Event name
*
2. Event organiser / organisation
*
3. Main contact name
*
First Name
Last Name
4. Email address
*
example@example.com
5. Phone number
*
Please enter a valid phone number.
6. Proposed event date(s)
*
7. Format
*
In person
Online
Hybrid
8. Location (if applicable)
9. Expected number of participants
*
10. Is this a recurring event?
*
Yes
No
11. If yes, attach a summary of previous feedback/evaluation
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Section 2: Educational Content
12. Brief description of the event
*
13. Learning objectives
*
14. Target audience
*
Consultant or equivalent
ST3 - ST8 or equivalent
CT1 - CT2 or equivalent
FY1 - FY2 or equivalent
Other
15. Pre-requisites (if any)
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Section 4: Programme Details
Attachments required
16. Please attach a full programme, including named faculty
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17. If you are unable to provide a full programme document, outline the details below
18. Details of any commercial or industry support / sponsorship
19. Conflict of interest summary (for all speakers/faculty)
*
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Section 5: Good Practice Checklist
20. Please indicate below that the following event best practices have been considered
*
Yes
No
Diversity of faculty representation
Accessibility for attendees
Parent/child facilities available/nearby
Dietary/religious/medical requirements catered for
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Section 6: Declaration
21. Tick to acknowledge the following
*
I confirm that the information provided is accurate and complete
I confirm that all relevant conflicts of interest have been declared
22. Please use this space to include any further details you would like to include in support of your application
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