1 Start 2 Complete The purpose of this intake request is to triage and provide the CME office enough general information on your activity request to support a systematic planning process. The request allows us to determine whether we can support your activity, however it does not guarantee conference coordination services. Consultation with the CME office required to navigate the Continuing Education Application and associated accredited documentation. Recommended timeline for developing accredited CE activities are essential 4-6 months (existing) and 9-12 months (new requests).The key to a successful CME activity is to contact CME office early to adhere to the rigorous expectations and accreditation requirements required by accrediting organizations. Title of Activity Proposed activity title Activity Date Proposed activity date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20242025202620272028 Activity Format Indicate the expected activity type. Live - In-Person Only Virtual Only Both - Hybrid Other format? Activity Format Other format? Physician Planner Committee Chair Department or Division Activity Contact Please identify the responsible program contact - Email and Phone Target audience? Who is the target audience? (Check all that apply) Physicians Specialty Physicians Primary Care Physicians Advanced Practice Providers Nursing Social Work Therapists Health Professionals Team Other. Target audience? Other. Targeted area? What is the targeted area? (Check all that apply) Children's Colorado Only Local Regional National International Other. Targeted area? Other. Will you seek additional professional credits (i.e. AAFP, NCPD, etc) for this activity? Additional fees may apply (Check all that apply) AAFP ABP MOC2 ASHA CRCE DIETARY EMS NCPD SOCIAL WORK OTHER Other. Will you seek additional professional credits (i.e. AAFP, NCPD, etc) for this activity? Other. Educational Need What educational need of the target audience will this activity address? Professional Practice Gaps Accredited Continuing Education must be designed to impact Competence, Performance and/or Patient Outcomes. What is the problem in practice? Do you expect to receive any financial support from outside of Children’s Colorado (commercial support, vendors, grants, etc)? Additional fees may apply Yes No Please specify Do you expect to receive any financial support from outside of Children’s Colorado (commercial support, vendors, grants, etc)? Please specify Are any organizations (besides Children’s Colorado) sponsoring or helping to promote and/or hold the activity? Children's Colorado participates in a limited number of Jointly Provided collaborations with procedures in place for accreditation requirements. Additional fees may apply Yes No Joint Provider or Other Organizations Are any organizations (besides Children’s Colorado) sponsoring or helping to promote and/or hold the activity? Joint Provider or Other Organizations Assistance requested of CME office Please note: Assistance requested does not guarantee that level of service from the CME office. CME consultation required to determine the level of assistance the CME office will be able to provide. Check all that apply Registration Meeting Management (contracts, catering, av, etc.) On-site support Marketing Grant Applications Exhibitor Assistance other: Assistance requested of CME office Assistance other: Anything else the CME office should be made aware of Proposed activity title Please share any relevant details to support your activity request. Leave this field blank
