Ada Canyon Medical Education Consortium CONTINUING MEDICAL EDUCATION REGULARLY SCHEDULED SERIES APPLICATION Please type all information except signatures. Handwritten applications will not be accepted. Section A: General Information ACMEC Affiliation: Boise VAMC West Valley MC Other: NONE St. Luke’s: (location) (please specify) Activity Coordinator The individual responsible for the operational and administrative support of this series. Name: (name, credential) Title: Mailing Address: Telephone: Fax: Email: physician The who has overall responsibility for planning, developing, implementing, and evaluating the content Activity Director and logistics of this series. Name: (name, credential) Title: Mailing Address: Telephone: Fax: Email: Planning Committee Any other people chiefly responsible for the design and implementation of this series. Name and Credentials Email Affiliation Content Expertise (Add additional rows as necessary) Note: Disclosures will need to be submitted for everyone involved in the planning and delivery of this series. Section B: Series Information Type of Series: Grand Rounds Tumor Board Case Conference M & M Other (please specify): Series Title: Series Location: City & State: (Hospital/Practice/Organization) Series Start Date: Series End Date: Frequency: Weekly Bi-Monthly Monthly Quarterly Enduring Material Other First Week Second Week Third Week Fourth Week (please specify): Monday Tuesday Wednesday Thursday Friday Time of Lecture: Anticipated # of Participants: (Start time AM/PM End time AM/PM) – CME Credits Per Occurrence Requested: Total Series CME Credits Requested: Other CE Credit NONE Nursing Osteopathic Pharmacy Other (please specify): Offered:
Ada Canyon Medical Education Consortium CONTINUING MEDICAL EDUCATION REGULARLY SCHEDULED SERIES APPLICATION Please type all information except signatures. Handwritten applications will not be accepted. Section A: General Information ACMEC Affiliation: Boise VAMC St. Luke’s: West Valley MC Other: NONE (location) (please specify) Activity Coordinator The individual responsible for the operational and administrative support of this series. Name: (name, credential) Title: Mailing Address: Telephone: Fax: Email: Activity Director The physician who has overall responsibility for planning, developing, implementing, and evaluating the content and logistics of this series. Name: (name, credential) Title: Mailing Address: Telephone: Fax: Email: Planning Committee Any other people chiefly responsible for the design and implementation of this series. Name and Credentials Email Affiliation Content Expertise (Add additional rows as necessary) Note: Disclosures will need to be submitted for everyone involved in the planning and delivery of this series. Section B: Series Information Type of Series: Grand Rounds Tumor Board Case Conference M & M Other (please specify): Series Title: Series Location: (Hospital/Practice/Organization) City & State: Series Start Date: Series End Date: Frequency: Weekly Bi-Monthly Monthly Quarterly Enduring Material Other First Week Second Week Third Week Fourth Week (please specify): Monday Tuesday Wednesday Thursday Friday Time of Lecture: (Start time AM/PM – End time AM/PM) Anticipated # of Participants: CME Credits Per Occurrence Requested: Total Series CME Credits Requested: Other CE Credit Offered: NONE Nursing Osteopathic Pharmacy Other (please specify):