How many hours are required to complete the program? Name of physician organization that developed the self-assessment program Name of physician organization: Address: Name and contact information for Email: Telephone #: requesting accreditation: Website address: First Name: Last Name: Contact information for Address: main point-of-contact Email: Telephone#: First Name: Last Name: Name and contact information for Email: Telephone #: Scientific Planning Committee Chair: Address: (If different from above) Name and contact Name of organization: information for Address: organization developing the activity Email: Telephone #: – only applicable if activity was Is the co-developing organization a physician organization? Yes No Will the physician organization maintain attendance records for 5 years? Yes No Content development Was the content developed by the applying physician organization? Yes No If no, who developed the content? Scientific planning committee members (SPC) Complete the table below. Include it as an attachment if you have this information already available electronically. Is the individual a member of the How does the individual represent physician organization Name of SPC member target audience? responsible for planning the CPD activity? Example: Jane Smythe, MD Endocrinologist Yes
How many hours are required to complete the program? Name of physician organization that developed the self-assessment program Name and contact information for requesting accreditation: Name of physician organization: Address: Email: Telephone #: Website address: Contact information for main point-of-contact 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 activity – only applicable if activity was Name of organization: Address: Email: Telephone #: Is the co-developing organization a physician organization? Yes No Will the physician organization maintain attendance records for 5 years? Yes No Content development Was the content developed by the applying physician organization? Yes No If no, who developed the content? Scientific planning committee members (SPC) Complete the table below. Include it as an attachment if you have this information already available electronically. Name of SPC member How does the individual represent target audience? Is the individual a member of the physician organization responsible for planning the CPD activity? Example: Jane Smythe, MD Endocrinologist Yes developing
form-section-3-application-e.docx