A completed copy of this form must be submitted 45 business days prior to the activity date. Failure to fill out this form completely and on time will result in refusal of the activity.

Speakers

  1. Please download the faculty disclosure form and complete it using Acrobat Reader. The completed form should be saved to your computer and attached to this application.

Activity

What is the title of this activity?

Enter the name of the event below.

If you have an agenda or schedule for this event, attach it below.

What date(s) will this activity take place on?


What type of activity will this be?


How many credit hours is this activity? This must be in increments of 0.25.

List 3–5 learning objectives below.

Choose the designator code related to your activity.







Who is the target audience for this activity? Check all that apply.







How do you plan to announce this activity? Check all that apply. Final activity announcements must be approved by the continuing education office prior to dissemination.






If you have a promotional brochure for this activity, attach it below.

Activity Content

How will activity content be delivered to participants?


Attach an outline of your activity below.

How do you plan to disclose conflicts of interest to activity participants?



Please provide 3 to 4 keywords describing activity content from this list.

What educational methods do you plan to use in this activity?






How will participant learning and accomplishment of learning objectives be assessed?