Meeting Accreditation Form

CARIBBEAN COLLEGE OF FAMILY PHYSICIANS CME ACCREDITATION REQUEST FORM (APPENDIX 12)

19a Windsor Avenue, Kingston 5, Jamaica, Tel: 876-517-6636 or 876-946-0954; Website: www.caribgp.org Member of the World Organization of Family Medicine National Colleges and Associations (WONCA) Please note that a separate application is required for each day and application must be submitted at least one (1) month prior to the event. (APPROVED BY THE CARIBBEAN COLLEGE OF FAMILY PHYSICIANS - CCFP)

APPLICANT/ORGANIZATION *

ADDRESS *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

EMAIL ADDRESS: *

CONTACT TELEPHONE # *

NAME OF CONTACT: *

First

Middle

Last

LOCATION OF CME ACTIVITY: *

DATE OF ACTIVITY: *

HOURS OF ACTIVITY: *

NUMBER OF DAYS REQUESTING ACCREDITATION *

MEETING/SESSION ACCREDITATION *

(please indicate if you are requesting a meeting or session accreditation only)

COURSE ACCREDITATION *

(please indicate if you are requesting course accreditation only)

DURATION OF COURSE *

(please indicate duration of course in days or months)

CO-ORGANIZER

TITLE OF PROGRAMME/ACTIVITY: *

PROGRAMME OUTLINE/COURSE OUTLINE

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(if file cannot be uploaded, please email to familydoctorsregional@gmail.com

COURSE/WEBINARS/MEETING PROGRAM AGENDA (MANDATORY)

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(if file cannot be uploaded, please email to familydoctorsregional@gmail.com

PLEASE UPLOAD CVS/BIOS FOR PRESENTERS

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(if file cannot be uploaded, please email to familydoctorsregional@gmail.com

PROGRAMME GOALS *

PROGRAMME OBJECTIVES *

DESCRIPTION OF EDUCATIONAL METHODOLOGY TO BE USED (use the other option to list all the educational methodology to be used): *

METHOD OF PROGRAMM EVALUATION:(use the other option to list all the options) *

CREDIT HOURS REQUESTING (PER DAY OR PER SESSION) *

WEBINARS/FACE-TO-FACE MEETINGS/WORKSHOPS ONLY - CME/WEBINARS/MEETING ACCREDITATION - I understand that there is an administrative cost for processing this application. Application for Chapters (in good standing) is US$150.00 per day: Affiliates of CCFP/Other Chapter- US$200.00 MCJ-NCCME/US$300.00 CCFP-NCCME per day. Application for Non-Affiliates is US$300.00 MCJ-NCCME/US$350 CCFP-NCCME per day. There is an additional cost for the Medical Council of Jamaica (if accreditation is required for Jamaican Physicians of J$7,500. *

I am a Chapter of CCFP (in good standing)
I am an Affiliate/other chapter of CCFP
I do not need MCJ Accreditation
I am a non-Affiliate of CCFP (not a chapter/not affilliated)
Not applicable

ONLINE/ON DEMAND COURSE CME/ACCREDITATION -I understand that there is an administrative cost for processing this application. Application for Chapters in good standing is US$300.00: Affiliates/Other Chapters is US$500.00. Application for Non-affiliates is US$800.00. *

I am a Chapter (in good standing)
I am an Affiliate/Other Chapter
I am a non-member of CCFP (not a chapter/not affilliated)
Not applicable

FACE-TO-FACE MEETINGS/ONLINE/HYBRID MEETING/ON DEMAND COURSE CME ACCREDITATION & CME: (REQUESTING CREDITS (CMES) FOR JAMAICA, REGIONAL AND OWN JURISDICTION- I understand that there is an administrative cost for processing this application. Application for Chapters in good standing is US$200: Affiliates/Other Chapters is US$400. Application for Non-affiliates is US$500.00. *

I am a Chapter (in good standing)
I am an Affiliate/Other Chapter
I am a non-affiliate of CCFP (not a chapter/not affilliated)
Not applicable

FACE-TO-FACE/ONLINE/HYBRID/ON DEMAND/TRAINING COURSES- ACCREDITATION & CME: (REQUESTING CREDITS (CMES) FOR JAMAICA, REGIONAL AND OWN JURISDICTION- I understand that there is an administrative cost for processing this application. Application for Chapters in good standing is US$200: Affiliates/Other Chapters is US$400. Application for Non-affiliates is US$500.00. *

I am a Chapter (in good standing)
I am an Affiliate/Other Chapter
I am a non-affiliate of CCFP (not a chapter/not affilliated)
Not applicable

PLEASE NOTE: PAYMENT INFORMATION (Cheque made payable to the Caribbean College of Family Physicians or Direct Deposit to A/C#903674078, Bank of Nova Scotia, Liguanea Branch, Account type: USD Savings Account; or J$ A/C#0650267 Cheguing or Current Account or you can contact us for other options to pay. An estimate will be provided upon receipt of your application. and your invoice will have other payment link to make payment directly to our account *

The Applicant is responsible for distribution of CME Certificates to attendees *

Yes
Need CCFP to distribute Certificates

A list of the attendee is to be provided to the CCFP at the end of the event *

Noted

MEETING/CME ACCREDITATION ONLY: The applicant is responsible for designing its own promotional flyer, email CME Certificates to attendees and promoting event (if you require the CCFP to design flyer and promote event and email certificates to attendees please indicate), as these attract additional costs *

ONLINE/ON DEMAND CME ACCREDITATION ONLY: The applicant is responsible for designing and promoting it online/on demand course. Applicant are to ensure that the signed CME Certificates for the attendees can be downloaded by each participant after completion of the course. (For promoting the online/on demand course an additional cost will be applicable. *

Yes
Not Applicable
Maybe
I need 2 email blast for promoting event

Yes
Not Applicable
Maybe
I need 2 email blast for promoting event

Yes
Not Applicable
Maybe
I need 2 email blast for promoting event

Cost for additional Services are as follows. Please indicate that which is applicable *

Cost for additional Services are as follows. Please indicate that which is applicable (copy) *