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Required Forms for a Continuing Education Activity

PRE-ACTIVITY

  • CE Planning Document [PDF - 740 KB]
    All CE activities must meet our accrediting bodies' criteria to be eligible for CE. This comprehensive CE Activity information and planning document serves as an initial guide through the requirements and process. It is used to initiate the educational design process for a CE activity which includes a description of the activity, the purpose and desired goals, learning outcomes/objectives, and identifies the planners of the activity.
  • Agenda - include a program agenda indicating start and end times for all presentations, breaks, and lunches, etc.
  • Faculty List with Disclosure Statement - selected faculty should be experts in the subject matter the activity covers. The results of the disclosure process must be added to the Faculty List (if multiple speakers will be listed) and/or on the promotional material.
  • Speaker & Planner Disclosure /Biographic Data Form [PDF - 59 KB]
    To award credit, all those in a position to control the content of an educational activity must disclose all relevant financial interest. "Relevant financial relationships" are defined as financial relationships in any amount occurring within the past 12 months that create a conflict of interest. If an individual refuses to complete the disclosure form, s/he will be disqualified from being a planning committee member or speaker, and cannot have control of, or responsibility for, the development, management, presentation or evaluation of the activity. Signed disclosure forms must be provided to coordinator at least one week in advance for review of any potential conflict of interest. If the review cannot be accomplished before the activity, the presentation cannot be designated for CE credit.
  • Draft Publicity/Marketing/Promotional Material - prior to promoting the activity, all publicity materials are reviewed for accurate accreditation language and to ensure the Joint Accreditation statement and logo are correctly displayed. No statement such as "CE credit applied for" or "credit pending" may be used.
  • Activity Evaluation [Word - 25 KB]
    All activities must be evaluated for effectiveness including the changes the healthcare teams intend to make in their practice as a result of participating in the activity. In addition to immediate feedback from participants, we encourage outcomes (or follow-up) data be measured for impact of learning.
  • Financial Revenue-Expense Worksheet, if applicable - a report of anticipated income and expenditures, including the sources of expected financial support. A budget is not required if the activity is solely supported by the agency and there are no monies appropriated other than the CE fees. This is required to identify and appropriately manage any commercial support if any.
    Note: The IHS CSC does not accept financial or in-kind support from commercial interests.

POST-ACTIVITY

  • CE Course Sign-In Sheet [Word - 79 KB]
    Used to verify attendance for participants who wish to claim credit for attending the activity.
  • Overall Evaluation Summary - A summary of the planning committee's analysis of the evaluation data and the conclusions reached about its effectiveness. This is now reported online. The link will be sent to the coordinators.
  • Physician Teaching Credit Request Form [Word - 50 KB]
    Physician (MD or DO) faculty may be awarded credit based on a 2-to-1 ratio to presentation time. For example, faculty may be awarded 2 AMA PRA Category 1 Credits™ for a 1-hour presentation that was designated for AMA PRA Category 1 Credit™. Credit may only be claimed once for an original presentation; credit may not be claimed for subsequent presentations of the same material. Physician faculty may not claim credit as a participant for their own presentations; however, they may claim credit for other segments they attend as a participant at a certified live activity.