CPD Course Approval Application

Is this a Renewal Application?*

Yes
No

The following information will be used for the ACHENA Approved Course Listing. Please complete this section exactly how you would like it to be listed on the ACHENA website.

Course Title:*

Note: This course title is used to identify which other form submissions (Instructor Bio, Financial Disclosure, etc) are to be paired with this application. Please make sure the course title entered in those form submissions match the title entered here exactly.

Course Provider(s)*

Course Presenter(s)

(if different from provider)

Course Date(s)

(if live)

Course Registration link*

Number of CPD hours you are applying for:*

Type of Training*

(check all that apply)

Live training
Pre-Recorded Training (enduring materials or activities)

Live Training*

In-person ONLY Conference/Seminar (no online attendance)
Live Webinar (online attendance)
In-person AND online attendance

Pre-Recorded Training*

Recording of live training offered subsequently
Webinar
CD/DVD
Other

Other training type*

Person responsible for Administering this Course:

Name*

First Last

Title

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Human Resources

Person responsible*

List the name of the individual responsible for administering this activity (include name & credentials)

CPD Planning Committee*

List the names of CPD planning committee members. This application must include at least two individuals who served as CPD planners or faculty. The individual named above as responsible for administering the activity may be included as a planning committee member. Please list the name, degrees, and credentials and attach a biographical data form with the additional required information. Planning Committee must include at least one person with active certification in homeopathy, such as CCH or other homeopathic credential.

Please list name, degrees and credentials for each CPD Planning Committee member.

Name	Degree	Credentials

Target Audience and Needs Assessment

(use additional space as needed)

Intended/target audience*

Evidence of Need*

(What evidence do you have of the continuing education need by healthcare professionals for this program? See Guidelines for further explanation.)

File

Evidence of Need - File upload (optional)

Max. file size: 32 MB.

**For Renewals*

(Explain what evidence you have which demonstrates the continued need for this program since your previous application.)

Professional Practice Gap*

(What is it that professionals do not know or are not doing that that this activity addresses? How did you identify this gap?)

**For Renewals*

(Explain how you identify a continued professional practice gap since your previous application, which this activity addresses.)

Educational Activity Overview

Do not provide answers on this sheet - This information is completed in appendix A.

Presenters/Content Specialists

List the names, degrees and/or credentials of each presenter/content specialist.
If they haven't already, please have each presenter/content specialist fill out and submit the Instructor Bio Form (Appendix B) and Disclosure Form (Appendix C).

Presenter(s) Name(s), Degrees and/or Credentials*

Names	Degrees	Credentials

2. Learners will be informed of presenters’ declaration of vested interests or lack of vested interest by OTHER:*

Commercial Support

Does this activity have commercial support?*

This activity HAS NO financial commercial support
This activity HAS NO “services in-kind” commercial support
This activity HAS commercial support *
This activity HAS “services in-kind” commercial support *
This activity HAS received support from entities other than commercial interests (e.g. non-profit organizations or government grants).

Please specify source of support*

Commercial support has been provided by:*

Commercial support provided by these organizations will influence the objectives and content of this activity.*

Yes
No

Learners will be informed about commercial support by:*

(Please complete the following regardless of commercial support)

Announcement at beginning of event/session. (There must be written verification that announcement was made.)
Information provided on advertising.
Information provided on handouts and/or slides.
Signs placed inside or outside of presentation or exhibit room.
Other – Describe:

4. Learners will be informed about commercial support or lack of commercial support by OTHER*

Learners will be informed of presenters’ declaration of vested interests or lack of vested interest (from Appendix C Disclosure form) by (check all that apply):*

Announcement at beginning of event/session.
Information provided on advertising.
Information provided on handouts and/or slides.
Signs placed inside or outside of presentation room.
Other – Describe:

Evaluation

How will this course be evaluated? (The evaluation form must be approved before the course, and you must submit a summary of the evaluations after the course.)

Check or describe the methods of evaluation to be used:*

(Check all that apply)

Participant evaluation/satisfaction tool (required for all events.)
Knowledge survey (Specify below)
Skill and attitude change (Specify below)
Change in practice/performance (Specify below)
Relationship of practice change to quality of service (Specify below)
Evaluation of learning outcomes (pre or post test; demonstration)
Other - Describe

Specify or describe (from above):*

Submit a copy of the evaluation tool(s) to be used for this event.*

It must include, at a minimum, questions about (a) achievement of objectives, (b) teaching effectiveness of each presenter, (c) whether the course was fair, unbiased and free of commercial influence, and (4) amount of time needed to complete the activity (enduring materials only).

NOTE: See Sample Evaluation Form included on CPD Course Application page https://achena.org/forms/

Max. file size: 32 MB.

Describe how evaluation data will be used to:*

(check all that apply)

Revise future presentations of this course
Create new courses
Other - Describe:

Describe how evaluation data will be used to OTHER*

Learner Feedback: Identify how feedback will be provided to the learner*

Question and answers during activity
Return results of testing
Follow-up communication
Other - Describe:

Learner Feedback OTHER*

**For Renewals: Quality Improvement

Describe any changes or improvements made to the delivery methods of this course since your previous application.*

Describe how have you used participant evaluation feedback to make adjustments or improvements to this course.*

If applicable, what advancements in the field of homeopathy have impacted the content of this course? How have you applied those advancements to course content?

Explain why the content of this course is still relevant to the continuing education needs of the professional homeopath.*

Publicity

Include a draft of brochure and/or publicity.*

ACHENA must review the brochure before it is printed. For web-based courses this information must appear BEFORE registrants log in. All publicity must clearly state what participants can expect including:

purpose and objectives of the course
intended audience
any special background requirements for attendance
time to complete the course (average or range for web-based courses)
continuing education credit information (See Guidelines. Language is very specific and must be included in publicity when credit is to be given.)*

*NOTE: You may not distribute any publicity with these statements until your proposal has been approved by ACHENA.

Max. file size: 32 MB.

Verification of Participation and Successful Completion

Indicate how participation will be verified:*

(check all that apply)

Sign-in/attendance sheets
Completion of post- training evaluation survey
Other (describe):

Indicate how participation will be verified OTHER*

Criteria for successful completion:*

(check all that apply)

Attendance at entire event
Completion/submission of evaluation form
Achieving a passing score on the post-test (enter score below)
Other (describe):

Passing Score or Other*

Participants will be informed of criteria by:*

(check all that apply)

Information on brochure/advertising materials
Verbal statement at beginning of event
Written information on handouts/website
Other (describe):

Participants will be informed of criteria by OTHER*

CPD Course Approval Application

Person responsible for Administering this Course:

Human Resources

Target Audience and Needs Assessment

Educational Activity Overview

Presenters/Content Specialists

Commercial Support

Evaluation

**For Renewals: Quality Improvement

Publicity

Verification of Participation and Successful Completion

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