Thank you for your interest in Continuing Education (CE) for Healthcare Professionals! Please fill out this form to the best of your ability. A CE Specialist will contact you to discuss further. Contact Information: First Name * Last Name * Email Address * Please provide the email address we should use to contact you UW School, Program or Department Organization/Company Name Is your organization engaged in addressing community/population health issues as related to the content of this activity? Yes No Please fill out this form to the best of your ability. If you are unsure how to complete something, you may leave it blank. A CE Specialist will contact you to discuss further. General Activity Information If you are planning a Regularly Scheduled Series (e.g., Grand Rounds, M&M, Journal Club, etc.), please use our RSS Request Form Please indicate the type of CE activity (Check all that apply) * Live (e.g. conference) Live Webinar Online Course Other Enduring (e.g. journal article) Performance Improvement (e.g. MOC Part IV) Other (e.g. learning from teaching) Please describe: Please indicate the type of CE activity (Check all that apply) Other (e.g. learning from teaching) Please describe: NOTE: You selected Regularly Scheduled Series (RSS) as your activity type. Please fill out the RSS Request Form instead. Title of the CE activity you are planning Event Date(s)/anticipated online launch date Proposed location and venue of this activity Anticipated number of hours of instruction * <1 hour 1 - 4 hours >4 - 8 hours >8-12 hours >12-16 hours >16 hours Unsure Briefly describe the general content focus of the accredited CE activity: Is this activity intended to meet the educational needs of two or more professions of the healthcare team? Yes No Describe your primary audience: List any additional potential professions who would benefit from attending: Geographic extent of your target audience: Internal (UW Health and ICEP member school faculty, clinicians, and staff only) Local On-Campus (Dane County area) Local Off-Campus (Specific community in or out of Dane County) Regional (Wisconsin and bordering states) National/International (USA and or abroad) Planning Committee Names, email addresses, and credentials of people who are currently part of your planning process.Note: UW-Madison ICEP will contact members of your planning committee to request a conflict of interest (COI) report upon approval of the activity. Nurses: Pharmacists: Physician Assistants: Physicians: Social Workers: Psychologists: Health Professions Students, including Residents and Fellows: Patients/Patient Family Members: Community Members: Other: Number of faculty and presenters you anticipate will be involved in this activity: Funding for this activity (check all that apply) Registration fees Commercial support (e.g., industry grants, in-kind support) Exhibits Advertising Non-commercial support (e.g., foundations, community partners) UW departments, schools, or programs Other: Funding for this activity (check all that apply) Other: Credit(s) you would like to make available to your learners: (check all that apply) Medicine AMA PRA Category 1TM (CME) Medicine AMA PRA Category 1TM (CME) with MOC Part 2 (only available for the following Boards: ABA, ABIM, ABO, ABOHNS, ABPath, ABP, and ABS Nursing ANCC Nursing ANCC with Pharmacotherapeutic Credit for APNs Pharmacy ACPE Physician Assistant AAPA Category 1 CME Psychology APA Social Work ABSW-ACE Other: Credit(s) you would like to make available to your learners: (check all that apply) Other: Has this activity been accredited before? Yes, by ICEP Yes, by another provider No, it has not been accredited previously Name of provider(s) who accredited this activity in the past: In the event that circumstances would make a live event impossible/impractical, which alternate format(s) would you consider? Live Stream (with real-time facilitation of the event, audience interaction) Video Capture (asynchronous presentation of content available on-demand) Live Stream & Video Capture (asynchronous and synchronous presentaion of content, live audience engagement) None. This activity requires in-person learning to meet the intended outcomes Other: In the event that circumstances would make a live event impossible/impractical, which alternate format(s) would you consider? Other: Leave this field blank
