DPC-form-proposal-course

CE - Proposal Form for Continuing Education Course
Identification of main trainer
Name*

Family nameFirst
Name of second trainer (where applicable)

Family nameFirst
Email*
Affiliation
Preffered date of training course
Preffered time of training course
Preferred month
Preffered day
Total number of participants (including webcast, where applicable)
Intended recipients of training course : List all information that will be relevant to the participants (e.g., level of familiarity with the topic or the clientele covered by the training)
Are there any prerequisites to the training course?

YesNo
Specify the prerequisites, e.g., readings or specific experience
The training relates to the following clientele(s):

Preschool childrenSchool-age childrenAdolescentsAdultsSeniorsOther
Information about the training course
Title*
Summary (max. 250 words, text to be used for promotional purposes and to present your training course to clinicians)*

0/250
Five bibliographic references
Learning objectives (at the end of the training, participants will be able to) :
Academic approaches
What is the anticipated link with clinical practice?
Training plan
Declaration of conflict of interest
Is there an actual, potential, or apparent conflict of interest?

YesNo
Specify
Note that “the declaration of actual or potential conflicts of interest must be made verbally and supported by a detailed slide shown to the participants before beginning the presentation” (excerpt from CPASS newsletter, 2012, p. 7). A formal written declaration must also be submitted prior to giving the training course (“Disclosure of potential conflict of interest,” form, Faculty of Medicine, Continuing Education department).
Do you give permission for your training course to be webcast (no recording, synchronous mode only)?

YesNo
Materials required for your training course (screen, projector, video projection equipment, clickers, etc.)
Should be Empty:

CE - Proposal Form for Continuing Education Course