SHA Application Form for CME/CPD Accreditation

Program Detials

Application No.

Program title

Program Date

Start Date

End Date

Program timings

Start Time

End Time

Program Venue & Address

Program Details (Ojectives & Outcomes):

Objectives

Outcomes

Knowledge

Competence

Performance

Quality Improvement/Patient Outcomes

Other (please list below):

Activity Delivery Mode

Onsite

Webinar

Hybrid

Program Information based on delivery mode:(Within 3 weeks from approval date)

Live Activity: Attach the activity topics/content (e.g., agenda, brochure, program book, or announcement).

Virtual Activity: Provide a direct link or URL with generic login(s) and password(s), if necessary for access, or, if text based, a complete copy of the activity. (WebEx,…)

State the reason(s) for giving the program (Check all that apply.)

Public health concern

Infection control

Patient safety

Quality Management

Case report

Changes to procedures or protocols

Advanced treatment modalities

New equipment or systems Others (please list below):

Program Evaluation Method(s)

Ask learners how the knowledge impact his/her

practice

Survey

Sample focus group of learners

pre/post session questions

Others (please list below):

Target Audience:

Field of specialty or subject area: (Please Specify):

Have you applied for accreditation of your program with other entities?

Yes

If yes, please provide the entity name and your application status:

Application Detials

Organization seeking accreditation:

Licensed by SHA:

Yes

If No, please provide the entity name:

Place of Issuing Trade License:

Affiliated/Accrediting Academic or Training Organization?

Yes

If yes, was the program approved by Education Unit/Committee in your facility:

Program Contact Person:

Job Tiltle:

Telephone No:

Mobile No:

Email:

Sponsor Name(s):

Name

Upload/View

Agenda of the program / include start and end times of each part of the educational program, registration, breaks, and Q&A times.

Presentations slides

Curriculum Vitae (CV) of the lecturer/speaker

A copy of the medical license for medical facilities in the private sector

Valid professional license for the speaker/instructor

Speaker Declaration Form

Healthcare facilities, Healthcare institutes with less than 50 technical staff names and contact details of the technical staff in the private medical facility.

Medical license for medical facilities in the private sector

Yes

Trade license of the site / Medical facility license

Recorded video of webinar presentation and PowerPoint presentation.

Yes

Post webinar quiz (at least 10 MCQ for 1 hour lecture)

Yes

Payment Receipt

Comments

Note:Photo format:.jpg,.jpeg,.pdf,.pptx | Maximum size:5MB

Facility Code