CE Assessment Form (JPS)

This form is designed to help facilitate the planning and evaluation of a continuing education activity.

The purpose of this form is to ensure that this educational initiative or activity aligns with the larger institutional quality and patient safety goals.

Upon submission, someone will contact you within 1-2 business days.

Please note that this form can be saved by scrolling to the bottom and selecting the "save and continue later" button.

Name(Required)

First Last

Email(Required)

Phone(Required)

JPS 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 determinined.

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.)

Other - Length of session

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

E.g. Trauma patients are at a higher risk of morbidity and mortality.

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

E.g. Lack of cutting-edge knowledge on key traumatic injury.

What evidence do you have that supports this need?(Required)

Chart data

Critical incidents

Local public health data

Literature

Questionnaires/surveys

Practice Guidelines

Expert consensus

Other (please list below)

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, etc.

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

E.g. Integrate new knowledge/strategies resulting in better competence leading to improved patient outcomes.

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 the new knowledge, applying new knowledge, adopting new skill or strategy or changing behavior?(Required)

E.g. Providers not having time to review the latest journal articles, lack of access to resources, EMR does not readily support the new strategies/diagnostics/treatments.

How will you know the activity is successful? (check all that apply)(Required)

Audience response during activity

Audience response after the activity

Case based questions

Chart reviews

Check off skills lists

Pre/post knowledge test

Post knowledge test

Summary patient data

Other (please list below)

Other - Activity success measure

Which professions would benefit MOST from this activity?(Required)

Other - Profession types

Who will be on the planning committee for this activity?(Required)

Please use + sign to add additional rows. Include everyone who is involved with the planning of the activity.

Name

Degree

Profession

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

Please list known or potential partner organizations you are working with on this activity.

Do you plan to seek funds from JPS Academic Affairs to support your activity?(Required)

If yes, then please download and complete the JPS Budget form.

Click here to download a copy of the JPS Budget Request. You will be required to upload it in the next section before moving on.

Please upload completed JPS Budget Request form here.

Drop files here or

Max. file size: 10 MB.

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

What organizations specifically do you plan on seeking funds from?

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 24 hours to discuss your CE program.

CE Assessment Form (JPS)

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CE Assessment Form (JPS)

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