Request for Joint Sponsor or Co-Sponsor Proposal

Please complete as much of this form as possible.  Mandatory items are marked with an asterisk.

User Information

First Name*
Last Name*
Company*
Title*
Address*
Address 2*
City*
State*
Zip Code*
Phone*
Fax*
E-mail*

Program Format

Proposed Program Topic*
Requested CME/CE hours
Program Format

Live Audioconference/Videoconference

Proposed Date(s) for Live Audioconference or Videoconference
Estimated Attendance for Live Audioconference or Videoconference

Subscribe to Groups

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Live Program

Proposed Date(s) for Live Program
Proposed Locations for Live Program
Estimated Attendance for Live Program

Enduring Materials

Program Media for Enduring Materials
Proposed program release date for Enduring Materials
Proposed program expiration date for Enduring Materials
Estimated Distribution for Enduring Materials
Estimated % CE Post-test return on distribution for Enduring Materials

Program Plan

Target Audience (Check all that apply)
Target Audience continued: If you chose Other Physicians or Other Healthcare Professionals, please explain.

Subject Matter

Subject Matter: Physicians (Check all that apply)
Subject Matter: Pharmacists (Check all that apply)
Subject Matter: Nurse Practitioners (Check all that apply)
Subject Matter: Nurses (Check all that apply)
Statement of Need
Overall Course Goal
Intended Outcome

Offering Data

Learner Objectives:

( At least 2 objectives per contact hour)
At the completion of this program the participant should be able to:

Content Outline:
Teaching Methods:

(Examples: Lecture, Panel Discussion, Case Study)

Evaluation Methods:

(Examples: Pre-Test, Case Studies, Simulations, Data Analysis)

Clinical Recommendations

Clinical Practice Recommendations:

(Note: All the recommendations involving clinical medicine in a CME activity must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.)

This program will include clinical practice recommendations:
Clinical Evidence in support of clinical practice recommendations:

(Note: All scientific research referred to, reported or used in CME in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection and analysis.)
No Selections are required. The following web sources may be useful in locating evidenced-based practice recommendations.

Web source:

Evidenced-based

Please list evidenced-based research to be utilized in this activity:

Fees

Would you suggest a fee for this activity?
If yes, what would be your proposed fee?

Commercial support

Commercial Support:
Amount of grant: $
If yes to Commercial Support, commercial support will be provided by:
Company Name:
Representative:
Address:
Telephone:
Fax Number:
Email Address:

Proposed Faculty

Proposed Faculty:

(If there is more than one Faculty Member, please submit a word document with this information and Faculty resume below in section 14.)

Name:

Credentials:
Address:
Telephone:
Fax Number:
Email Address:

Attach Resume or Other Documentation

Do you have a resume or other documentation you would like to send?

If yes, email your documents to Mimi Holman.

Proposed Marketing Tools:
If Other selected, please specify:

Joint Sponsor

Joint Sponsor
Company Name:
Representative:
Address:
Telephone:
Fax Number:
Email address:
Is Joint Sponsor an accredited provider through the following groups?
ACCME:
ACPE:
If yes, what is your ACPE Provider #:
ANCC:
AANP:

Additional notes

If you have any additional notes or comments, please provide them below.

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type in the code below:

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AKH Inc.
Advancing Knowledge in Healthcare

P.O Box 2187
Orange Park, FL 32067-2187
(904) 683-8843
Fax (904) 683-3803