Web Form submitted - Powered by Keap

Interesting Image

Rapid COVID-19 CME Proposal

Please submit this form to request CME credit for upcoming COVID-19 education for Partners staff. Our goal for turnaround is 1-2 business days.

**Starting 8/1/20 CPD will start charging fees for approved Covid-19 activities. We were please to provide CME without charging fees in April-July.**

First Name *
Last Name *

Email *

When will the activity take place?

Activity date & time. If recurring, provide start date. *

Frequency (e.g. one-time, monthly, daily, weekly, etc.) *

Activity title. (If none, leave blank.)

Number of people likely to attend? *

Is the activity designed to address COVID-19? *

YesNo

If yes, proceed

Is the expected outcome an improvement in response to COVID-19? *

YesNo

If yes, proceed

Will the activity be led by a facilitator or faculty member? *

YesNo

If yes, please provide leader’s name:

Do they own or work at a pharmaceutical or device company?

YesNo

If yes, an alternate person must lead the activity.

Will you collect attendance and send it to us to award credit? *

YesNo

How much time do you anticipate the activity will take? *

After the activity, I will outline any intended practice changes identified by participants. *

YesNo

Planners from which professions helped develop this activity? *

PhysiciansNursesPAsOther

Additional information or details

We will contact you with accreditation information after we receive this form.