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.
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Presentations slides
Upload
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Curriculum Vitae (CV) of the lecturer/speaker
Upload
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A copy of the medical license for medical facilities in the private sector
Upload
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Valid professional license for the speaker/instructor
Upload
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Speaker Declaration Form
Upload
Download
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Healthcare facilities, Healthcare institutes with less than 50 technical staff names and contact details of the technical staff in the private medical facility.
Upload
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Medical license for medical facilities in the private sector
Yes
No
Upload
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Change
Trade license of the site / Medical facility license
Upload
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Change
Recorded video of webinar presentation and PowerPoint presentation.
Yes
No
Upload
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Change
Post webinar quiz (at least 10 MCQ for 1 hour lecture)
Yes
No
Upload
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Change
Payment Receipt
Upload
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Comments
Note:Photo format:.jpg,.jpeg,.pdf,.pptx | Maximum size:5MB
Facility Code
Your request has been submitted to SHA successfully.
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