Name of for profit supporter Amount or in kind contribution anticipated or received: Describe how funds will be used; including who is responsible for paying speaker honoraria and travel: Is accreditation/certification for this program sought with any other organization or group? Yes, Name of Organization: ____________________ No This program is seeking: Group-Learning credits (e.g. conferences, rounds, journal clubs) Assessment credits (e.g. practice audits, QA programs, Linking Learning to Assessment, Provincial Practice Review) Self-Learning credits (e.g. online programs, Linking Learning exercises) Attachments PowerPoint slides, handouts and/or materials for the program Disclosure slides and objectives slides Items used in the needs assessment / summary of findings Program Agenda/ Brochure Conflict of Interest forms for the planning committee and speakers Summary of previous event evaluations Copy of program/presenter evaluation form Budget (including revenue and expenses) I __________________ (planning committee chair) confirm that all information in this application is correct __________________________________ ____________ Signature Date
Name of for profit supporter Amount or in kind contribution anticipated or received: Describe how funds will be used; including who is responsible for paying speaker honoraria and travel: Is accreditation/certification for this program sought with any other organization or group? Yes, Name of Organization: ____________________ No This program is seeking: Group-Learning credits (e.g. conferences, rounds, journal clubs) Assessment credits (e.g. practice audits, QA programs, Linking Learning to Assessment, Provincial Practice Review) Self-Learning credits (e.g. online programs, Linking Learning exercises) Attachments PowerPoint slides, handouts and/or materials for the program Disclosure slides and objectives slides Items used in the needs assessment / summary of findings Program Agenda/ Brochure Conflict of Interest forms for the planning committee and speakers Summary of previous event evaluations Copy of program/presenter evaluation form Budget (including revenue and expenses) I __________________ (planning committee chair) confirm that all information in this application is correct __________________________________ ____________ Signature Date
CertificationAccreditationApplication_v4(07July2016).docx