EmailMe Form - Partnership Inquiry Form

Contact Name *

Prefix First Last

Credentials *

Contact Email *

Contact Phone Number *

### - ### - ####

Agency or Organization *

Suggested Name of Continuing Professional Development Activity *

Suggested Date of Activity *

MM / DD / YYYY

Please include month, day and year.

Suggested Location of Activity

Include street address, city, state and zip code.

Has this activity been conducted previously? *

Yes

No

Was it in partnership with Piedmont AHEC? *

Yes

No

State the practice gap/issue this educational activity is trying 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 or documentation evidence supports this practice gap/issue? *

Please provide specific description and/or attach documentation (up to 3 files below)

File Upload

Briefly describe this educational activity. *

What are the proposed learning objectives for this 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 Piedmont AHEC could do to make your educational activity successful: *