Activity Information Date of application: (dd/mm/yyyy) Title of group learning activity: Activity end date: Activity start date: (dd/mm/yyyy) (dd/mm/yyyy) Delivery method of group learning Web-based Face-to-face activity: Both web-based and face-to-face Location How many times will this activity be 1 2 Estimated # of 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 group learning activity Name physician organization: of Address: Name and contact information for requesting Email: Telephone #: accreditation: address: Website First Name: Last Name: Contact information for main Address: Email: Telephone#: First Name: Last Name: Name and contact information for Email: Telephone #: Scientific Planning Committee Chair: Address: (If different from above) organization: Name of Name and contact information for organization Address: developing the
Activity Information Date of application: (dd/mm/yyyy) Title of group learning activity: Activity start date: (dd/mm/yyyy) Activity end date: (dd/mm/yyyy) Delivery method of group learning activity: Web-based Face-to-face Both web-based and face-to-face Location 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 group learning 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
GroupLearning-application_e.docx