Continuing Health Professional Education

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  • New Activity Information Form

    Activity Information Form

    * = Required Fields

    First Name:*
    Last Name:*
    Will you also serve as activity director?
    Note: Activity director must be full-time UMMC faculty member.*

    If no, who will serve as activity director?
    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:*
    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?*