Faculty CME application for single activity/event endorsement
Faculty name:
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Contact name:
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Contact email address:
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Name of the activity/event:
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Date of the activity/event:
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Location of the activity/event:
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Education hours applied for:
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Description of the activity:
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What is the purpose of this session and what are the anticipated outcomes:
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Does this activity/event acknowledge cultural competence, cultural safety, or health equity:
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Yes
No
Is there any sponsorship linked to the activity/event:
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Yes
No
Are there any potential sources of bias, conflicts of interest or contentious issues that could affect the impartiality of the activity/event:
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Yes
No
Mode of learning:
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In person
E-learning
Webinar
Other
Please attach:
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1. Activity/event programme 2. Evaluation form 3. Supporting documents (if applicable)
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