Continuing Education Leadership Program
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1. Continuing Education Leadership Program Application Form

Dear Applicant
Thank you for your interest in the The Continuing Education Leadership Program (CELP).

To apply, please complete the following steps.
STEP 1: Complete this online form.
STEP 2: Email a copy of your CV to : int1088@cmetoronto.ca with your name as the subject line.

Thank you
CELP Planning committee

1. Contact Information

Contact Information Name:
Institution:
Address 1:
Address 2:
City/Town:
State/Province:
ZIP/Postal Code:
Country:
Email Address:
Phone Number:

2. Please list your professional qualifications

Please list your professional qualifications

3. Gender:

Gender: Male

Female

4. What is your primary professional affiliation?

What is your primary professional affiliation? Medicine

Nursing

Pharmacy

Rehabilitation

Public Health

Other (please specify)

5. Number of Years in Continuing Education

Number of Years in Continuing Education 0-5 years

6-10 years

11-15 years

16-20 years

21-30 years

Over 30 years

6. How would you describe your comfort level with the following CE Competency areas? (1-Not comfortable, 5-Very comfortable)

	Not Comfortable		Neutral		Very Comfortable
Accreditation Standards	*How would you describe your comfort level with the following CE Competency areas? (1-Not comfortable, 5-Very comfortable) Accreditation Standards Not Comfortable	Accreditation Standards	Accreditation Standards Neutral	Accreditation Standards	Accreditation Standards Very Comfortable
Continuing Education Theories and Principles	Continuing Education Theories and Principles Not Comfortable	Continuing Education Theories and Principles	Continuing Education Theories and Principles Neutral	Continuing Education Theories and Principles	Continuing Education Theories and Principles Very Comfortable
Continuing Education Research	Continuing Education Research Not Comfortable	Continuing Education Research	Continuing Education Research Neutral	Continuing Education Research	Continuing Education Research Very Comfortable
Educational Technologies	Educational Technologies Not Comfortable	Educational Technologies	Educational Technologies Neutral	Educational Technologies	Educational Technologies Very Comfortable
Instructional Design	Instructional Design Not Comfortable	Instructional Design	Instructional Design Neutral	Instructional Design	Instructional Design Very Comfortable
Knowledge Translation	Knowledge Translation Not Comfortable	Knowledge Translation	Knowledge Translation Neutral	Knowledge Translation	Knowledge Translation Very Comfortable
Leadership	Leadership Not Comfortable	Leadership	Leadership Neutral	Leadership	Leadership Very Comfortable
Partnership/Collaboration	Partnership/Collaboration Not Comfortable	Partnership/Collaboration	Partnership/Collaboration Neutral	Partnership/Collaboration	Partnership/Collaboration Very Comfortable
Performance Measurement	Performance Measurement Not Comfortable	Performance Measurement	Performance Measurement Neutral	Performance Measurement	Performance Measurement Very Comfortable
Project/Business Management	Project/Business Management Not Comfortable	Project/Business Management	Project/Business Management Neutral	Project/Business Management	Project/Business Management Very Comfortable
Qulaity Improvement/ Patient safety	Qulaity Improvement/ Patient safety Not Comfortable	Qulaity Improvement/ Patient safety	Qulaity Improvement/ Patient safety Neutral	Qulaity Improvement/ Patient safety	Qulaity Improvement/ Patient safety Very Comfortable
Self-assessment and life-long learning principles	Self-assessment and life-long learning principles Not Comfortable	Self-assessment and life-long learning principles	Self-assessment and life-long learning principles Neutral	Self-assessment and life-long learning principles	Self-assessment and life-long learning principles Very Comfortable
Teaching Methods	Teaching Methods Not Comfortable	Teaching Methods	Teaching Methods Neutral	Teaching Methods	Teaching Methods Very Comfortable

7. Describe your current continuing education role:

Describe your current continuing education role:

8. Why do you want to participate in CELP? How will this help with your current role?

Why do you want to participate in CELP? How will this help with your current role?

9. What do you think is the most important thing facing the continuing education field today?

What do you think is the most important thing facing the continuing education field today?

As the final step for your application, we require an updated copy of your Curriculum Vitae (CV). Please send a copy of your CV via email to info-int1088@cmetoronto.ca with your last names as the subject line. Your CV must be received by January 15th, 2010.

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