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 No If yes, please provide the entity name and your application status:

Application Detials
Organization seeking accreditation:
Licensed by SHA:	Yes No If No, please provide the entity name:
Place of Issuing Trade License:
Affiliated/Accrediting Academic or Training Organization?	Yes No 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 No
Trade license of the site / Medical facility license
Recorded video of webinar presentation and PowerPoint presentation.	Yes No
Post webinar quiz (at least 10 MCQ for 1 hour lecture)	Yes No
Payment Receipt
Comments
Note:Photo format:.jpg,.jpeg,.pdf,.pptx \| Maximum size:5MB

Facility Code

Home
Approved
Partially Approved
Reverted
Resubmitted
Rejected
Report