New CME Activity Information Form

First Name:           

Last Name:           

Title of Proposed Activity: (the maximum length is 200 characters)
    

Proposed Dates:
Date1:  (mm/dd/yyyy)            

Date2:  (mm/dd/yyyy)     

Proposed Location:     (the maximum length is 150 characters)     

Type of Activity: (choose one)
Live
Enduring Material
PI CME
Journal-based CME
Test-item writing
Manuscript review
Internet point-of-care
     

Will you also serve as the activity director?       Yes            No
      If not, indicate name(s) of activity director(s):        
         Note: Activity director must be a full-time Johns Hopkins faculty member

Hopkins Sponsoring Department:     

Phone:  (xxx-xxx-xxxx)     

E-mail:           

Office Address:    

Describe why this activity is needed.  What is the professional practice gap that this activity will be designed to fill? (the maximum length is 255 characters)

 

Target Audience: (the maximum length is 255 characters)

 

Does this activity fit within our mission for CME?   click here to view Mission Statement.             Yes       No

Will commercial support be solicited?    click here to view Standards for Commercial Support.      Yes       No

Will another organization be involved in planning this activity?                                                   Yes       No

       If yes, name of organization: