Request a CME Activity Form

Request a CME Activity Form

Date of Request

Physician Contact Email*

Please enter one contact email for the physician that will lead the planning committee

Admin Coordinator Email*

Please enter one contact email for administrative coordinator that will provide key session dates

Activity Type*

RSS- Regularly scheduled series, such as Grand Rounds, Journal Club, M&M

Course- Annual conference

Enduring- On demand activity that does not have a specific time or location

Select or enter value

Activity Name*

Renewal*

Has this activity been approved in the past?

Select

Department*

Select

Desired Start Date*

Comments*

Please describe this activity. What are the learning objectives/QI initiatives that this activity will address?

File Upload

For new activities: you may submit a file describing the activity goals For renewals: you may submit an activity form for review

Drag and drop files here or

Send me a copy of my responses