Thank you for your interest in offering a Continuing Medical Education (CME) activity. Please complete this brief form so the CME Office can determine eligibility and next steps. If appropriate, you will be invited to submit the full CME application.

Question Title

1. Name of Requestor: (Required.)

Question Title

2. Title / Role:

Question Title

3. Department / Organization: (Required.)

Question Title

5. Phone

Question Title

6. Proposed Title of the Activity: (Required.)

Question Title

7. Has this course previously occurred / been accredited by the Office of CME? (Required.)

Question Title

8. Type of CME Activity Requested (select one): (Required.)

Question Title

9. Proposed Date or Timeframe: (Required.)

Question Title

10. Estimated Number of Learners: (Required.)

Question Title

11. Target Audience (select all that apply): (Required.)

Question Title

12. What clinical or professional practice gap will this activity address? (Required.)

Question Title

13. How was this need identified? (select all that apply) (Required.)

Question Title

14. What should learners be able to do differently after this activity? (Required.)

Question Title

15. Proposed Course Director(s) (if known): (Required.)

Question Title

16. Proposed Faculty or Speakers (if known): (Required.)

Question Title

17. Will there be any commercial support (educational grant or industry funding)? (Required.)

Question Title

18. Will any commercial company be involved in planning this activity? (Required.)

Question Title

19. Is any outside meeting planning or communications company involved? (Required.)

Question Title

20. Proposed format (select all that apply): (Required.)

Question Title

21. Estimated length of the activity: (Required.)

Question Title

22. Additional comments or information:

Question Title

23. How did you hear about us?

T