CE Assessment Form

Email(Required)

Phone(Required)

Organization/Sponsoring Department(Required)

Program Director for Activity(Required)

Activity Name:(Required)

(This can be a working title if you are not sure of the final title)

Activity Purpose:(Required)

Describe your activity in 3-4 sentences.

Proposed date of activity:(Required)

Please enter the proposed date of activity. Can be approximate if the exact date has not been determined.

Type of Activity:(Required)

You have selected unsure as to your activity type. Please contact the HSC continuing education team to discuss your activity options.

Conference

What type of conference?

Approximate # of CE hours.(Required)

Location of Conference

Series

What type of series?

Frequency

Length of each session (Half hour, hour, etc.)(Required)

Other - Length of session

What situation/problem is occurring that you hope to address with this educational activity?(Required)

E.g. Our quality measure for % of eligible patients needs improvement.

What is causing this situation/problem? (Need for knowledge, skills, strategy or application of knowledge/skills)(Required)

E.g. Visits marked Medicare Annual Wellness visits are not meeting the criteria, it seems several criteria are being missed.

Other - Evidence types(Required)

Please attach evidence here.(Required)

Drop files here or

Max. file size: 10 MB.

E.g. Needs assessment, clinical data, peer review articles, practice guidelines...

What does the ideal change look like in practice?(Required)

E.g. Marked Medicare Annual Wellness Visits meet all criteria and more eligible patients get that type of visit.

What are the main activity objectives? (These may be revised as the activity develops.)(Required)

Please review this educational resource for guidance and examples for developing effective educational objectives for the activity.

By the end of this educational activity, learners will be able to:

What would prevent learners from gaining new knowledge, applying new knowledge, adopting new skills or strategy or changing behavior?(Required)

E.g. Providers feel too rushed and that there are too many steps to remember in the Medicare Annual Wellness Visit, some providers don't see the benefit in all the steps.

Other - Activity success measure

Other - Additional profession types

Are there any partner organizations working together for this activity?(Required)

Do you plan to seek financial or in-kind support from any organization or commercial supporters to fund the activity?(Required)

Will a registration fee be implemented for the activity?(Required)

What is the planned registration fee or an estimate of the fee?

Do you plan to market this activity? (i.e. flyer, brochure, email, etc.)(Required)

Has any marketing already been distributed?(Required)

Please upload any marketing materials already created.

Drop files here or

Max. file size: 10 MB.

We appreciate your time and the information provided in this form. Please hit submit and someone from our office will contact you within 1 - 2 business days to discuss your CE program.

CE Assessment Form

Quick links

Resources

Connect with us

CE Assessment Form

Quick links

Resources

Connect with us

Social media