Hamad Medical Corporation

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:

------

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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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 : ------