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Save & Return
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The following application includes required fields in order to progress. To view the application in its entirety, click
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.
Activity Information
Activity Name
*
Start Date
*
+
End Date
*
+
Activity Format(s)
*
Course
Internet Live Course
Enduring Material
Internet Enduring Activity
Journal-based
Point-of-Care Learning
Other
Other
Location
*
In-person
Virtual
Platform
*
Zoom
WebEx
Microsoft Teams
Other
Other
Broadcast Link
Street Address
*
City
*
State
*
Which credits are you applying for? (check all that apply)
*
AMA PRA Category 1
Maintenance of Certification Part II
Social Work
Medical Ethics and/or Professional Responsibility
Pain Management
Which type of MOC Part II credit? (check all that apply)
*
American Board of Anesthesiology (ABA)
American Board of Internal Medicine (ABIM)
American Board of Ophthalmology (ABO)
American Board of Otolaryngology–Head and Neck Surgery (ABOHNS)
American Board of Pathology (ABPath)
American Board of Pediatrics (ABP)
American Board of Surgery (ABS)
Are you collaborating with other accredited providers on any of the following types of credit? (check all that apply)
Nursing
Physician Assistant
Pharmacy
Dental
Social Work
Other
Other
Activity Director
Name
*
Degree(s)
*
Academic Title
*
Affiliation
*
Email Address
*
Phone
*
Please review the
Activity Director Compliance Agreement
. A signed agreement needs to be submitted at the end of this application.
Is there an Activity Co-Director?
*
Yes
No
Activity Co-Director
Name
*
Degree(s)
*
Academic Title
*
Affiliation
*
Email Address
*
Phone
*
Please review the
Activity Director Compliance Agreement
. A signed agreement needs to be submitted at the end of this application.
Activity Coordinator
The Activity Coordinator serves as an additional point of contact. This person will handle most of the administrative and logistical functions for the activity; and is typically the Activity Director's assistant or administrative staff.
Name
*
Degree(s)
*
Academic Title
*
Affiliation
*
Email Address
*
Phone
*