CME Providers Form

Application for Accreditation of CME/CPD Activity

Note: CME/CPD activities will be registered only if the completed Application Form and all required details are received by the CME Center 3 weeks before the start of the activity. This procedure is in place to enable the organizers to announce the activity giving sufficient notice to prospective participants to make appropriate arrangements to attend.

I. Administration Details

1. Title of activity:

2. Scheduled date(s):

3. Duration (in hours) of educational sessions:

4. CME/CPD Provider (Name of institution/association):
(Click CME/CPD Providers for details on accredited providers.)

5. Organizing institution:

6. Name of organizer/coordinator of activity:

Contact address:
	Tel No.:
	Fax No.:
Email address:	Mobile/Pager:

7. Type of organizing institution:

Academic Hospital/Health Center Health professions society
Other :

II. Academic Details

8. Type of activity:

Symposium/seminar Conference Workshop Lecture series
Other :
9. Field of specialty or subject area:

10. Frequency of conducting activity (if to be repeated):

11. Aims and objectives:

12. Content outline:

13. Scheduling of sessions:

IMPORTANT
Under 13. Scheduling of sessions: above, the following information is ESSENTIAL for calculating credit points. Registration process CANNOT start until this information is received by the CME Center:
1. Starting and finishing times of each presentation and scheduled breaks, where indicated;
2. Title of each presentation;
3. Name of lecturer, demonstrator or instructor for each presentation, stating whether he or she is a local or external resource person)
4. Type of activity (lecture, group work, practical, clinical etc.) ]:

14.Target audience (number and background):

15. Plans for program evaluation:

On completion of activity,
i.	Submit Evaluation report on the program to the CME Center.
ii.	Retain List of Participants for future reference.
iii.	Issue Letter (Certificate) of attendance to participants.

If you wish to re-enter data, press

I certify that I have received approval from the CME Provider mentioned in the application for conducting this activity under its authority.

Press to send.
[Pressing SUBMIT button confirms that you have received authorization from the CME Provider (Under 4 above) to organize the activity under its umbrella.]

A message will appear indicating the data you submitted. Please print this data and keep the printout for future reference.

Once the application is received at the CME Center, the data will be processed for registration.

Contact the CME Center at Fax: 22467140 or email: <cmecenter@kims.org.kw> to make sure that your application was received.