Activity Information Date of application: Title of group learning activity: Activity start date: Activity end date: Web-based Face-to-face Delivery method of group learning activity: Both web-based and face-to-face 1 2 Estimated # of How many times will this activity be held? 3 4+ participants: Has the program been previously If yes, when was it Yes No accredited? reviewed? If yes, by which CPD accreditation system? How many hours are required to complete the program? PART A: Administrative Standards Name of physician organization that developed the learning activity Name of physician organization: Address: City: Province: Postal Code: Name and contact information for requesting Name: Title: accreditation: Telephone #: Website address: CPD Event website: Name and contact Name: information for Scientific Planning Committee Telephone #: Chair: (If different from Name of organization: Name and contact information for organization Address: the activity co-developing – only applicable if activity Telephone #: was co-developed: Is the co-developing organization a physician organization? A physician organization is defined by the Royal College as a not-for-profit group of health Yes No N/A professionals with a formal governance structure, accountable to and serving, among others, its specialist physician members through: continuing professional development, provision of health care, and/or research.
Activity Information Date of application: Title of group learning activity: Activity start date: Activity end date: Delivery method of group learning activity: Web-based Face-to-face Both web-based and face-to-face How many times will this activity be held? 1 2 3 4+ Estimated # of participants: Has the program been previously accredited? Yes No If yes, when was it reviewed? If yes, by which CPD accreditation system? How many hours are required to complete the program? PART A: Administrative Standards Name of physician organization that developed the learning activity Name and contact information for requesting accreditation: Name of physician organization: Address: City: Province: Postal Code: Name: Title: Telephone #: Website address: CPD Event website: Name and contact information for Scientific Planning Committee Chair: (If different from Name: Telephone #: Name and contact information for organization co-developing the activity – only applicable if activity was co-developed: Name of organization: Address: Telephone #: Is the co-developing organization a physician organization? A physician organization is defined by the Royal College as a not-for-profit group of health professionals with a formal governance structure, accountable to and serving, among others, its specialist physician members through: continuing professional development, provision of health care, and/or research. Yes No N/A