CE Applications and Forms

Main Content

New CE Activity Information Form

CHPE is excited to assist in planning and hosting your next continuing education activity. To begin the planning process we request that you complete the form below at least 90 days prior to your event if it is an Option A (where CHPE only issues credit), and a minimum of 120 days prior for full scale Option B conferences (where CHPE provides full support, or where exhibitors or commercial support is sought).

Once you complete this form the director of CHPE will assign a team member to lead the planning of your event. Then, either the director or the lead planner will contact you to begin discussions and planning. Thank you for your interest in providing a continuing education event.

* - Required field

First Name:* 
Last Name:* 
Will you also serve as activity director (or if a nursing activity- the nurse planner/coordinator)? Note: Activity director or nurse planner/coordinator must be full-time UMMC faculty member.*
If no, who will serve as activity director or, for nursing, the nurse planner/coordinator?
UMMC Sponsoring Department:* 
Phone Number:*() -    
E-mail Address:* 
Office Address:* 
Title of proposed activity:* 
Proposed date option 1.*
Start Date:*  
End Date:*  
Proposed date option 2.
Start Date: 
End Date: 
Expected number of attendees:* 
Proposed Location:* 
Type of Credit:*

Number of CE hours requested:* 
Type of Activity:*
Describe why this activity is needed. What is the professional practice gap that this activity will be designed to fill?* 
Describe the target audience, please include specific disciplines, and whether it is a UMMC only event, or if non-UMMC personnel will be invited.* 
Does this activity fit within our mission for CME?*
Click here to view our mission statement.
Will commercial support be solicited?*
Commercial Support: http://www.accme.org/requirements/accreditation-requirements-cme-providers/standards-for-commercial-support*
Will another organization be involved in planning ?*
If yes, who?
Are you interested in obtaining information to determine if this program meets Maintenance of Certification requirements?*