REQUEST FOR JOINT PROVIDERSHIP
CONTINUING EDUCATION FOR NURSES ONLY
The Perinatal Advisory Council (PAC/LAC) is an approved provider of continuing education by the Board
of Registered Nursing. Agencies who wish to provide continuing education credits through PAC/LAC
must complete and submit the Request for Joint Providership at least two months prior to the
scheduled activity. The request for joint Providership, along with all flyers, brochures, or marketing
materials must be approved prior to the continuing education activity. All requested materials must be
submitted to PAC/LAC at least one month prior to scheduled activity. Continuing education contact
hours are only valid upon PAC/LAC’s receipt of all required documentation.
SECTION A: JOINT PROVIDER INFORMATION
Date:
Requesting Agency:
Educational Partner(s):
Contact Person:
Address:
City, State, ZIP:
Tel. No.:
E-mail:
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SECTION B: ACTIVITY INFORMATION
Date of Activity:
Name of Activity:
Course Director/Chair:
Units Requested:
Continuing Education Contact Hours (Nurses)
(Each contact hour is at least 50 minutes of instruction in an organized learning environment. Breaks, lunch,
welcome and introductions do not count as educational time.)
Course Learning Objectives:
Educational Needs Assessment
Discuss why the TOPIC for this activity was selected. (Example: As a result of sentinel event, education was needed
on topic. The Director of the Department is going to discuss the risk management strategies to employ in this unit
to prevent further incidence.)
Target Audience:
Event Format: (e.g. noon conference, day long event; didactic, workshop, etc.) Discuss why format was chosen.
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SECTION B: ACTIVITY INFORMATION (cont’d)
Brochure/Flyer/Marketing Materials:
 Attach a draft of the agenda, brochure, flyers, and/or marketing materials with this request.
All brochures, flyers, and/or marketing materials must be submitted to PAC/LAC for review and approval
at least two months prior to the event and prior to distribution. They must contain:
-
PAC/LAC listed as a joint sponsor of the event
Intended audience
Learning Objectives
Agenda (list time, topic, faculty for each time slot)
Name and credentials of program faculty
Cost (if event is free, it must state so)
Cancellation or fund policy
Materials supplied (e.g. course syllabus, continental breakfast, lunch, etc.)
Notification of any commercial support
The full statement:
o
For Nurses: The Perinatal Advisory Council – Leadership, Advocacy and Consultation (PAC/LAC) is
an approved provider by the California Board of Registered Nursing Provider CEP 5862. This
course is approved for XX contact hours of continuing education credit.
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SECTION C: FACULTY & PLANNING COMMITTEE MEMBERS
List all members of the Planning Committee for this activity: (add additional rows if necessary)
List all faculty (e.g. speakers, panelists, moderators, course director, etc.) for this activity (add additional
rows if necessary).
 All faculty members must submit a copy of their CV or Resume at least one month prior to the
scheduled activity.
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SECTION D: REQUIRED MATERIALS AFTER CME ACTIVITY
The following materials are required from the Joint Provider within 30 days after the scheduled CME
activity. CME’s provided at the activity will not be honored if the following materials are not received by
PAC/LAC within this specified time frame.

Submit the following materials to PAC/LAC within 30 days after the Activity:
Administrative Fee ($250 for members, $300 for non-members)
Sign-in sheet
Evaluation Summary
Tally of attendees (e.g. # physicians, # RN’s, # social workers, # others, etc.)
List of attendees who received credit/certificate
Please make checks payable to PAC/LAC. Please submit all required materials together in one package.
If you have any difficulties obtaining all required materials or have any questions, please contact Jennie
Torti at (818) 708-2850 ext.103 or via e-mail at jennie@paclac.org. Please send all materials to:
Jennie Torti
PAC/LAC
5530 Corbin Ave., Suite 323
Tarzana, CA 91356
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