CME Credit
CME Code
HAMAD MEDICAL CORPORATION

Department of Medical Education

Office of Continuing Medical Education

(OCME)

APPLICATION FOR ACCREDITATION OF CME ACTIVITY

Name of Provider or Coordinator: ------

Corp. #: ------

Department: ------

Title of Activity: ------

------

Date: ------Location: ------

A.ACTIVITY INFORMATION

1.Type of Activity:

Conference

Symposium

Hospital Grand Round

Departmental Grand Round

Workshop

Practical / skills session

Case presentation

Question and answer session

Other ------

Contact Details:

Tel # : ______Mobile #:______

Bleep #: ______Fax #: ______

E-mail: ______

B.TARGET AUDIENCE

Please indicate the audience for which this activity is intended:

Hospital Staff

Primary Care

Dentists

Other

C. NEEDS ASSESSMENT

Which methods have been used to identify the need for this activity?

Literature review

Departmental meeting discussion

Expert opinion

Best practice guidelines

Quality improvement review

Recent research

Update of knowledge

New technique/procedure

Questionnaire

Discussions with colleagues

D.IDENTIFIED NEEDS

After analyzing the needs assessment data identified above, list the specific needs that will be addressed by this educational activity:

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------

------

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OBJECTIVES:

Please be specific about the learning outcomes resulting from attendance at the proposed activity. Please use active verbs. e.g. (participants will be able to describe, manage, diagnose, interpret, list etc...)

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------

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SPONSORS:

Name of sponsor(s): 1) ------

2) ------

3) ------

No funds should be paid from a commercial source directly to the Course Director, speakers, participants or any person involved in the activity.

It should be payable directly to Hamad Medical Corporation.

Letter of Agreement submittedYesNo

Attachments:

Please attach the following if applicable:

Program agenda

List of speakers

Departmental Approval:

I approve and recommend the implementation of this Continuing Medical

Education activity.

CME Officer:

Name: ------Date: ------

Signature: ------

Department Chairperson:

Name: ------Date: ------

Signature: ------

Office of Continuing Medical Education - Approval:

Name: ------Date: ------

Signature: ------

Credit points awarded to activity

------Credit points to provider

------Credit points to participant

Director of Continuing Medical Education:

------Date : ------