MedicusCME Joint Provider Pre-Application

Joint Provider Pre-Application

Prior to making application for AMA PRA Category 1 credit for your educational activity, please review the ACCME Standards for Commercial Support.
Activity Details
1. Activity title:
2. Activity start date:

MonthDayYear
Date
Anticipated End Date: (If this event extends for multiple days or if it will be available in web format, the End date will be later than the Start Date.)

MonthDayYear
Date
3. Activity type:

Live CourseRegularly Scheduled Series (Grand Rounds, Journal Club, Case Conference, M and M, etc.)Web format, Internet enduring materialPerformance Improvement Continuing Medical EducationOther
If "other", please describe below:
4. Provide brief overview of educational activity:
5. State the professional practice gap of your learners that is prompting this educational activity to be undertaken. This can best be described by comparing the current state of care within your department/organization to "best practice".
6. Target audience includes which of the following:

Primary Care PhysiciansSpecialty PhysiciansDentistsResidents and FellowsPhysician AssistantsNurse PractitionersRegistered NursesPharmacistsSocial WorkersOther Allied Health Professionals
7. Anticipated number of attendees:
8. Indicate source(s) of funding:

Institution/departmental fundsIndustry/commercial fundingUnrestricted educational grant/endowmentRegistration feesExhibitor feesOther
If "other", please describe:
9. Name of Course Director

First NameLast Name and Degree
10. Email address of Course Director
example@example.com
11. Name of Activity Coordinator:
12. Email address of Activity Coordinator:
example@example.com
14. Please provide any additional information here:
Name of person completing this application:

First NameLast Name
Date submitted:

MonthDayYear
Date
If the Submit button below is dimmed, you have not fully completed the application. Please review the form for any required fields (red asterisk) that you may have overlooked.
13. Please upload a Word .doc listing of all planning committee members and any additional individuals in control of content for this activity excluding the course director. The list should include the name and credentials (MD, DO, RN, etc.) of the individual, the practice specialty, the institution of employment, and her role (planning committee, faculty, topic advisor, etc.).

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Joint Provider Pre-Application

Activity Details