CE Pre Planning Form

Thank you for your interest in accredited continuing education (CE) for healthcare professionals! Please fill out this pre-planning form to the best of your ability. If you are not sure how to respond, select the answer that best fits with your current plans. You will have the opportunity to make changes throughout the planning process. A team member will contact you to discuss next steps in the CE application approval process.

Visit the Continuing Education Planning Page for information about continuing education requirements, planning, and timelines.

This form is for inquiries about developing and hosting courses on the CE Learning Platform, NOT for claiming credit for an activity you attended.

The IPCE Submitter Training will provide an overview of the procedures for submitting Interprofessional Continuing Education (IPCE) activities. Completion of this training is necessary to move forward with the Pre-Planning form.

To complete the IPCE Submitter training, please click here. After finishing the training, you may proceed to fill out the IPCE Pre Planning Form.

I attest to viewing the IPCE Submitter Training

Yes

No

Contact Information

Name of person who will be the primary point of contact for planning the education.

First name *

Last name *

Email address *

Activity Director *

Please list the name and title of the person who will be primarily responsible for developing the content of the education.

All members of the planning team must complete a disclosure form prior to completing an application for accreditation: Advocate Health Accredited Continuing Education Disclosure of Financial Relationships Form. Please note that owners or employees of ineligible companies cannot participate in the planning or presentation of accredited CE. Our accrediting body states that “ineligible companies” are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

I understand members of the planning team must complete a disclosure form prior to completing a application for accreditation: Advocate Health Accredited Continuing Education Disclosure of Financial Relationships Form. *

Yes

Activity Information

Name of activity *

Activity date *

Has this activity been accredited before? *

Yes

No

Activity Type *

Course (in-person or virtual - one time event)

Regularly Scheduled Series (i.e. grand rounds)

Journal CME/CE

Internet Enduring Material (on-demand learning)

Other...

Activity Type Other...

Where will your target audience (learners) be located? *

Please select all locations that your learners may be located. You may select multiple locations.

Enterprise (learners will be teammates from across Advocate Health)

Georgia

Illinois

North Carolina (Charlotte and surrounding areas)

North Carolina (Winston-Salem and surrounding areas)

Wisconsin

Other...

Where will your target audience (learners) be located? Other...

Where will the activity be held? *

Where will the activity be held? Other...

Activity Address *

Please share the address of the location including site, city, state, and zip code. Write "virtual" if your activity is not taking place at a physical location.

Credit(s) you would like to make available to your learners: (check all that apply) *

Joint Accreditation criteria require that Interprofessional Continuing Education activities are planned by and for the healthcare team. For activities that are focused on multiple professions, the planning team should reflect the professions and credit types being targeted by the activity.

Credit(s) you would like to make available to your learners: (check all that apply) Other...

Does the planning team represent the target audience and the credit type(s) you are requesting? *

For example: if the conference is requesting CME credit, then the planning committee would need to include a physician on the planning team.

Yes

No

Anticipated number of hours of instruction: *

How many total people do you expect to attend? *

Will the activity generate any income? Please check all that may apply. *

Will the activity generate any income? Please check all that may apply. Other...

State the professional practice gap(s) of the healthcare team/members on which the activity is based. *

This is the gap between what is currently happening in practice (where you are) and optimal performance in practice (where you want to be).

Select which of the following methods were used to determine the educational need described above? *

Please check all that apply.

Peer-reviewed literature, healthcare trends, and clinical practice guidelines

Regulatory, legal, or licensure requirements (e.g., state licensure boards, DEA requirements, CMS regulations)

Internal and external data sources (e.g., Key Result Area (KRA) data, quality metrics, patient outcomes, safety or performance data, public health statistics, epidemiology data, and national benchmark data)

Needs assessment and stakeholder input (e.g., learner surveys, activity evaluations, focus groups, meeting minutes, interviews, emails, and feedback from managers, subject matter experts, organizational leaders, and other stakeholders)

Advocate Health initiatives, strategic priorities, and new policies/procedures (e.g., Rewire 2030)

Other...

Select which of the following methods were used to determine the educational need described above? Other...

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Contact Information

Activity Information