Request for CE Certification

Request for CE Certification

Course Name*

Your First Name*

Your Last Name*

Your Email Address*

Your role in regards to the course*

How did course come about?*

How did this course come about? What is the purpose of this course?

How will this course improve patient outcomes?*

Identified Public Health Issue*

Will this course address a public health issue? If yes, please include which public health priority will be addressed.

Anticipated number of Learners*

How many learners do you anticipate will attend or participate in this course?

Anticipated number of planning committee members*

How many planning committee members do you anticipate will serve on the planning committee for this course?

Anticipated number of speakers*

How many speakers do you anticipate will speak at this course?

Target Audience*

What healthcare profession(s) are you designing the content for?

Credit Types*

Select all that apply

Select

Estimated number of credits*

Enter the number of credits that you are anticipate will be awarded to the course (1 credit = 1 hour of educational content; breaks, networking, etc. are not counted towards credit).

Will this course have concurrent sessions?*

Select

Course Format*

Select

Location*

Platform for Virtual Access (e.g. Zoom)*

Platform for housing enduring/distance content*

RSS Frequency*

Course start date*

Provide the confirmed or planned course date(s) for live courses or the anticipated launch date for online/enduring courses.

Frequency of additional sessions (e.g. monthly)*

Estimated number of additional sessions*

Registration Services*

OCPD fees include registration services through our CE Portal.

Services include:

Learner and customer support service via email, phone and CE Portal self-service tools. Includes information on how learners can access the CE Portal and complete steps required to obtain CE/attendance documentation
Online Join Mailing List Form for interested persons to sign up to be notified when registration for your course opens
Learner access to registration receipts and confirmations
Regular registration reports provided to Course Director and Planning Committee members
For live virtual or hybrid events- optional webinar access link provided to learners through their CE Portal account

Are you planning on using OCPD registration services?

Select

Course Director and Planning Committee*

The planning committee should represent your audience. As an example, if you plan to have both physicians and nurses in your audience the planning committee should have at least one of each of those profession types. As part of the course certification request review process, the individuals identified below will be asked to complete or review and update their disclosure in our CE Portal. They will receive more information and instructions via email.

For each planning committee member, provide the following:

First and last name
Degree (e.g. MD, APRN)
Email address

Disclosure Completion Prior to Planning*

By checking the box below, course directors acknowledge that course planning cannot occur until disclosures for all planning committee members are completed in the CE Portal.

How is this course funded?*

How is this course funded (e.g. registration fees, grants, departmental budget funds)?

Commercial Support and Exhibits

RSS courses are not eligible to receive commercial support and/or exhibit funds per OCPD policy.

There are compliance considerations for commercial support and exhibit opportunities for all course types. Courses that intend to submit grant applications for educational support funds will be required to have a grant-focused meeting with OCPD staff and complete an additional attestation if grant funding is sought.

Commercial Support (Grants)*

Will this course seek commercial support (educational grants and/or in-kind grants)?

Select

Exhibit Opportunities*

Are you planning to offer exhibit or other promotional opportunities for this course?

Select

Exhibit Plans*

Enter your preliminary plans for exhibit support, including opportunities available and companies you plan to invite.

UMN/MHF Affiliation*

Is the organization planning the course an internal University of Minnesota and/or M Health Fairview Department?

Select

UMN/MHF Department*

List the name of the department(s).

Organization Eligibility*

Does your organization produce, market, sell, re-sell or distribute healthcare products used by or on patients?

Yes

Description of Organization*

Describe the organization(s) involved in developing the content of this course. For example, are you a non-profit, healthcare provider, government entity, etc? Include links to org charts or other information you think would be helpful to someone to understand your organization.

Planning Status*

What is the planning status? (i.e. needs assessment complete, preliminary agenda drafted/finalized, etc.)

How did you hear about us?*

Thank you!

Thank you for your interest in partnering with the University of Minnesota Office of Continuing Professional Development. We will follow-up with you within 7 business days.

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