Program Information Form
Program Title:
Target Audience:
Presentation Date:
Synergy CERP Topic Category:
Select One
M/D/Y
Total Contact Hours:
If you have multiple courses that have different CERP categories, use the space below to assign total contact hours for each CERP topic category
Synergy CERP Category A:
Synergy CERP Category B:
Teaching Method: Check all that apply
Question & Answer
Case Study Discussions
Role Playing
Simulation
Synergy CERP Category C:
Lecture
Skills Practice Session
Panel Presentations
Posters
Small Group Discussion
Other:
Attendee Evaluation Tool: Check all that apply
Knowledge Enhancement (Post-test)
Learner Satisfaction (Survey)
Skills Demonstration (Hands-on)
Program Description states the foundation for why the learners are coming together. It serves to tie the target audience and
their learning needs to the objectives. It is a simple statement such as: “Inform about advances in the practice” or “Engage learners
in a discussion about potential changes to practice guidelines” it is not a repeat of the objectives.
The purpose of the program is: Limit your response to the space provided.
Participant Learning Objectives
Based on the needs assessment, learning objectives illustrate what the participant should be able to do (knowledge, skills, and/or
practice) as a result of the educational activity. They are statements that describe learner-orientated outcomes.
Be sure all objectives: Use verbs which describe (the learner outcome, not the instructor’s approach) an outcome that can be
evaluated in some form; Consist of one or two action verb(s) per objective; Are supported by the teaching strategies.
At the end of the session(s) the attendee will be able to: Limit your response to the space provided.
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Schedule & Content Outline
A Brochure Cannot Be Substituted For This Form
Content
The content section is a succinct description of information that will be presented to accomplish the objectives. It is related to
and consistent with the objectives but is not a restatement of the objective; it is a list of topics which will be addressed.
Time Frame
The time frame is the estimate of time needed to present the content and accomplish the learning objectives. It can include
time for disclosure, question and answer period, completion of participant feedback or other tools, or completion of tests and
review responses, it does not include registration, introductions, breaks, time to walk between rooms, or viewing of exhibits.
Content
Provide a detailed outline to cover the presentation time frame.

Each outline item must be specific enough to provide a full description of the
content.
 Do not repeat the learning objectives.
Time Frame
Provide the time
frame and
minutes for each
topic.
Presenter
List the presenter(s)
for each topic.
One session presentation per row. For programs with multiple presentations, please use the Title field to separate.
Title:
min.
Title:
min.
Title:
min.
Title:
min.
Title:
min.
Title:
min.
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Content
Time Frame
Presenter
Title:
min.
Title:
min.
Title:
min.
Title:
min.
Title:
min.
Title:
min.
Title:
min.
Title:
min.
Title:
min.
Winter 2013 Update
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