Thank you for your interest in planning an accredited CE activity with GW's Office of Continuing Education in the Health Professions (CEHP). The first step in planning a CE activity is to complete this CE Planning Form. This short form requires you to submit basic information about your planned activity. Upon receiving your activity, a CEHP staff member will follow-up with you within 3 business days. Please contact the CEHP office should you have any questions while completing this form. Full Name * Email Address * Phone * Which of the following best describes your relationship with GW? * SMHS Faculty/Staff GW Hospital GW Medical Faculty Associates Children's National Health System Washington DC VA Medical Center Other, please describe: Which of the following best describes your relationship with GW? Other, please describe: Are you submitting this form on behalf of the Course Director/ Lead for the activity? * Yes, I am not the Course Director/Lead for this activity No, I am the Course Director/Lead for this activity Course Director/ Activity Lead Course Director's First Name Course Director's Last Name Course Director's Email Address Which of the following best describes the Course Director's relationship with GW? SMHS Faculty/Staff GW Hospital GW Medical Faculty Associates Children's National Health System Washington DC VA Medical Center Other, please describe: Which of the following best describes the Course Director's relationship with GW? Other, please describe: Activity Details Activity Name/ Title * What kind of activity are you planning? * Live Course Internet Live Course Enduring Material RSS/Grand Rounds Other, please describe: What kind of activity are you planning? Other, please describe: Activity Start Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Is this the: * Actual Date Proposed Date How long is your activity? i.e. # of days or # of hours * How many presenters and/or facilitators will be involved in the activity? * Which credit types would you want to award? (Select all that apply) * Nurse (ANCC) Pharmacist (ACPE) Physician (ACCME) Physician Assistant (AAPA) Psychologist (APA) Social Worker (ASWB) Other: Will this activity have commercial support (grants or in-kind donations)? * Yes No Uncertain Will this activity be planned/implemented in collaboration with an external partner(s)? * Yes No If yes, please provide the name of the external partner(s) What GW CEHP services are you interested in? (Select All that Apply) * Please note: CEHP no longer provides event/meeting planning services (budget, faculty management, logistics coordination, and marketing) Accreditation Certification Services Grant Procurement Services: identify/submit proposals and budgets, secure LOAs, present outcomes and reconciliation Evaluation Services: creation, collection, and reporting Instructional Design and Module Development Services Registration Services: collection, processing, and reconciliation Access to Learning Management System Other, please describe: What GW CEHP services are you interested in? (Select All that Apply) Other, please describe: Please provide any additional details that you would like CEHP to know about the planned activity. If available, please provide a preliminary agenda for your activity? Files must be less than 2 MB.Allowed file types: gif jpg jpeg png pdf doc docx xls xlsx. Leave this field blank
