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New CE Activity Information Form

* - 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?* 
Target Audience:* 
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?*