on-line synchronous group learning activity Activity Type: blended group learning activity Application Date : Activity (mm/dd/yyyy) (mm/dd/yyyy - mm/dd/yyyy) Name of organization requesting accreditation: Governmental healthcare professional academic institution Non-governmental healthcare professional academic institution Governmental healthcare facility Non-governmental healthcare facility Organization type (check one): Other healthcare professional organization If you have selected healthcare professional organization” please provide a “other brief description of the organization including the organization’s mission, governance structure and indicate whether the organization is “for-profit”. Name of Primary Contact for organization applying for Email: accreditation: Phone number: Address: Intended Allied health professionals target Complementary medicine audience of How many times will this activity Dentists the activity be held within the next 12 1 2 3 4+ Nurses (please months? Pharmacists check all Physicians that apply): Other (please list): No Approximate Has this program been Yes number of accredited by another accrediting If yes, please describe: anticipated body? participants: Please describe the process by the organization will determine the actual amount of hours each participant will be eligible to record for credit. Please describe the process by which the organization will distribute certificates of participation to all participants. PART A: Administrative Standards (to complete this section, refer to Part A: Administrative Standards OSBGL Administrative Standard 1.1-1.3) Scientific Planning Committee The SPC is ultimately responsible for the following program elements:
Activity Type: on-line synchronous group learning activity blended group learning activity Application Date : (mm/dd/yyyy) Activity (mm/dd/yyyy - mm/dd/yyyy) Name of organization requesting accreditation: Organization type (check one): Governmental healthcare professional academic institution Non-governmental healthcare professional academic institution Governmental healthcare facility Non-governmental healthcare facility Other healthcare professional organization If you have selected “other healthcare professional organization” please provide a brief description of the organization including the organization’s mission, governance structure and indicate whether the organization is “for-profit”. Name of Primary Contact for organization applying for accreditation: Email: Phone number: Address: Intended target audience of the activity (please check all that apply): Allied health professionals Complementary medicine Dentists Nurses Pharmacists Physicians Other (please list): How many times will this activity be held within the next 12 months? 1 2 3 4+ Approximate number of anticipated participants: Has this program been accredited by another accrediting body? No Yes If yes, please describe: Please describe the process by the organization will determine the actual amount of hours each participant will be eligible to record for credit. Please describe the process by which the organization will distribute certificates of participation to all participants. PART A: Administrative Standards (to complete this section, refer to Part A: Administrative Standards OSBGL Administrative Standard 1.1-1.3) Scientific Planning Committee The SPC is ultimately responsible for the following program elements:
CPD-Application-Category1-On-line-Synchronous-and-Blended-Group-Learning.docx