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1. Name of Organization

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2. Provider ID Number

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3. Primary Contact

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4. Billing Contact

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5. CEO Contact *CEO contact will only be contacted if we are unable to contact the Primary and Billing contact.

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6. Check the organization category that most accurately describes your organization and CME program and provide details related to the category you select.

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7. Is your organization part of a larger healthcare system?

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8. If yes, name the larger organizational healthcare system.

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9. Number of hospitals or medical centers owned by your organization and supported by your CMA CME accredited program.

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10. Number of clinics/sites owned by your organization and supported by your CMA CME accredited program.

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11. What is your geographic location(s) considered?

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12. What is the total full time equivalent (FTE) staffing dedicated to your CME program? (1.0 FTE = 40 hours/week)

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13. What are your organization's top 3 priorities for CME in the coming year?

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14. What are the top 3 challenges your organization faces in regard to CME?

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15. Which best describes your CME program support from organizational leadership?

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16. What strategies are you using to demonstrate the impact and value of your CME program to your leadership?

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17. How can CMA better support your CME program?

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