Date of application: (dd/mm/yyyy) Title of simulation activity Activity end date: Activity start date: (dd/mm/yyyy) (dd/mm/yyyy) Delivery method of Web-based Face-to-face Both web-based and face-to-face simulation activity: How many times will this 1 2 Estimated # of activity be held? 3 4+ participants: Has the activity been If yes, when was it Yes No previously accredited? reviewed? If yes, by CPD accreditation system? What is the maximum number of hours required to complete the simulation activity? Name of physician organization that developed the simulation activity Name physician organization: of Address: Name and contact information for Email: Telephone #: requesting accreditation: address: Website Contact information First Name: Last Name: for main Address: Email: Telephone#: Name and contact First Name: Last Name: information for Scientific Planning Email: Telephone #: Committee Chair: (If different from Address: above) organization: Name of Name and contact information for organization Address: developing the
Date of application: (dd/mm/yyyy) Title of simulation activity Activity start date: (dd/mm/yyyy) Activity end date: (dd/mm/yyyy) Delivery method of simulation 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 activity been previously accredited? Yes No If yes, when was it reviewed? If yes, by CPD accreditation system? What is the maximum number of hours required to complete the simulation activity? Name of physician organization that developed the simulation activity Name and contact information for requesting accreditation: Name of physician organization: Address: Email: Telephone #: Website address: Contact information for main First Name: Last Name: Address: Email: Telephone#: Name and contact information for Scientific Planning Committee Chair: (If different from above) First Name: Last Name: Email: Telephone #: Address: Name and contact information for organization the Name of organization: Address: developing
MOC3-Performance-Assessment%28SIM%29_1.docx