Proposal For A Continuing Education Course
|[pic] |INDIAN HEALTH SERVICE CLINICAL SUPPORT CENTER |[pic] |
| |40 North Central Avenue, Suite, 780 ▪ Phoenix, AZ 85004 ▪ P: (602) 364-7777 ▪ F: (602) 364-7788 | |
| |Website: | |
|PROPOSAL FOR A CONTINUING EDUCATION COURSE |
|Please complete this form and send it to us as soon as you begin thinking about an activity. |
|1. New Activity | Renewal |Previous File #: | | |
|2. Activity Start Date: | |Activity End Date: | | |
|3. Do you plan to repeat this activity in the next 12 months? | Yes No | |
|If yes, list additional dates if known: | |
|4. Delivery Methods (check all that apply): |
| | Live in Person | Live | Enduring Material – Internet | Enduring Material – Other | |
| | |Internet-based (WebEx) |based self-study |(journal, etc.) | |
|5. Primary Teaching/Learning Strategies (check all that apply): |
| | Didactic Lecture | Workshops/Seminar | Other: | |
| |Case Studies |Demonstration |Other: | |
| |Questions and Answers |Panel Discussion |Other: | |
| |Hands-on Practice |Roundtable |Other: | |
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|6. Location of Activity: | |
|7. Activity Title: | |
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|8. Brief Description of the Activity: | |
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|9. Primary Goal of the Activity (Ex: to increase knowledge, skills and attitudes; to improve competence; to enhance patient health status, etc.): | |
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|10. Is there any revenue for this activity or are any expenses being paid? Yes No |
|11. List the Sources from which you will choose presenters: | |
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|12. Contact Person: | |Title: | |
|E-mail Address: | |Phone: | |
|Address: | |Fax: | |
|City/State/Zip: | | | |
|Requesting Facility/Service Unit/Organization: | |
|Type: IHS | Tribal/638 | Urban Program | Other (explain): | |
|13. CE Target Audience: | Physicians | Nurses | APNs | PA | Pharmacists | Dental |
| | Other: | |
|14. Type(s) of credit you are requesting: |
| CME (Continuing Medical Education – AMA) |
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|CPE (Continuing Pharmacy Education - ACPE), additional criteria must be met. |
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|ADA (American Dental Association – CERP/DANB) |
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|CNE (Continuing Nursing Education - ANCC) |
|Each educational activity must be planned collaboratively by at least one nurse planner. Collectively, the members of the planning group should represent the |
|relevant content expertise, the target audience, and responsibility adherent to ANCC provider criteria. Nurse planners contribute oversight and must be actively |
|involved in both the planning and the analysis of evaluation data for the educational activity. Please identify the nurse planner in SECTION 15 of this form. |
|PROPOSAL FOR A CONTINUING EDUCATION COURSE |
|15. Planning Committee: Any person who contributes to the planning and course content and/or can influence the goals or objectives of the course. NOTE: The Planning|
|Committee MUST include at least one representative from each profession for which you plan to offer continuing education credit – Please provide actual names and |
|credentials. |
| |Name AND Credentials: |Title: |Attached |
| | | |Disclosure |Bio |
|Ex: |John Saari, MD |Physician Educator | | |
| |Linda M. Trujillo MSN, BSN, RN |Lead Nurse Planner, IHS, Clinical Support Center (Nursing CE) | | |
| | |Nurse Planner (must be identified if seeking nurse credit) | | |
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|14. Checklist: Please attach or send in the following necessary documentation to complete your file before the first scheduled activity: |
| Needs Assessment Form & Narrative |
| Itemized Agenda (showing actual current dates/times including breaks and lunches) |
| Learning Objectives |
| Faculty List with appropriate faculty disclosure statement |
| Signed and Completed Speaker and Planner Disclosure Forms |
| Speaker and Planner Biographic Data (page 2 of Disclosure Forms) |
| Evaluation Tool |
| Promotional Material (Draft publicity/marketing material, flyers, brochures, email announcement, website screenshots) |
| Financial Revenue-Expense Worksheet - if you answered “Yes” to SECTION 10. |
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