EmailMe Form - Continuing Education Partnership Inquiry Form

Continuing Education Partnership Inquiry Form

Thank you for being interested in working with the Piedmont Area Health Education Center (AHEC). Please provide the following general information about the continuing education program or activity for which you wish to partner with the Piedmont AHEC.

Upon completion, please click on the [Submit] button at the bottom of the form.

Our Educational Activity Review Committee will consider your request within seven days of receiving it. If we are able to move forward with your proposal, a representative will contact you to discuss the next steps.

Contact Name: *
Prefix First Last
Contact Email: *
Contact Phone: *
### - ### - ####
Agency / Organization: *
Suggested Name of Continuing Educational Activity: *
Suggested Date of Continuing Educational Activity: *
MM / DD / YYYY
Note: Your application must be received a minimum of 90 days prior to the educational activity. Due to pre-approval requirements for CME, CNE, or ACPE credit, activities offering any of these require that your application be received at least 9 months prior.
Suggested Location of Continuing Educational Activity (optional):

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Has this activity been conducted previously? Was it in partnership with AHEC? *
State the practice gap/issue this educational activity is seeking to address: *
Note: The practice gap is the difference between what actually occurs and what the ideal or evidence-based practice should be, or, the problem the activity is trying to solve.
What data, documentation, evidence do you have that supports this practice gap / issue? *
Please provide specific description and/or attach documentation (up to 3 files below)
Briefly describe the educational activity: *
What are the proposed learning objectives for the educational activity? *
What measureable outcomes are you seeking that will indicate the described educational activity will overcome the practice gap / issue stated above? *
What is the target audience for this educational activity and the estimated number of attendees? *
How do you plan to cover expenses for this educational activity? *
Please add any additional information you believe will help us understand what Greensboro AHEC could do to make your educational activity successful: