Office of Continuing Professional Education
FOR OFFICE OF CPE USE ONLY
ACCME_
Date Rec'd
_______
Application Fee $
*
Date Reviewed
File Name_
ACCME Credits Approved
ACCME: Competence/Performance/Patient Outcomes *Fee is Non-refundable
ACPE__
ACPE Credits Approved
How is change measured?
ACPE Type: Knowledge/Application/Practice
Continuing Professional Education Application
Note: Application must be submitted 6 weeks prior to the activity date
($100 rush fee may be applicable if submitted less than 6 weeks prior to the activity date)
I.
Proposed Activity Information
Program Title:________________________________________________________________________
Activity Date: ________________________________________________________________________
Location (city and venue) : ______________________________________________________________
Requested Accreditation Period for Enduring Material:  6 mths  1 year  2 years  3 years
A. Type of Activity (Check all that apply):
 ACCME- Medicine Credit
 ACPE- Pharmacy Credit
 Live Activity (eg, symposium, conference, etc.)
 Internet: Live (eg, web broadcast, webinar, live demonstration)
 Enduring Web-based
 Archived Webcast
 DVD  Other: _____________________
Regularly Scheduled Series
The ACCME defines a Regularly Scheduled Series as an activity that plans to have a series with
multiple sessions; occur on an ongoing basis (offered regularly weekly, monthly, or quarterly); and
sessions are primarily planned by and presented to the accredited organization’s professional staff.
 Grand Rounds
 Journal club
Case Conference
 Morbidity & Mortality
 Other: _______________________
Frequency:  Weekly
 Monthly
 Quarterly
 Other: _____________________
Day of the week: __________________________
Time duration:
Start Time: _________am/pm
Hiatus:
 Yes
 No
Will RSS be broadcast live?
End time: ___________am/pm
If yes, when? _______________________________________
 Yes
Method:  Video Conference
No
 Internet Feed Other: _____________________
Locations: ______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
B. CE Sponsorship
 Direct Sponsorship (Fully managed by NEOMED OCPE)
 Joint Sponsorship (Non-ACCME accredited provider seeking program credit)
Organization Name: ______________________________________________________
Address: _______________________________________________________________
City: __________________________
II.
State: _______ Zip: ______________________
Leadership
A. Activity Director (Affiliated with NEOMED content expert who has overall responsibility for
developing, planning, implementing, and evaluating the content of the activity)
Name: _____________________________________ Degree (initials): _________________
Affiliation /Dept: ______________________________ Title: __________________________
Address: __________________________________________________________________
City: ____________________________
State: ________ Zip: _____________________
Phone: __________________________
Fax: __________________________________
Email: ____________________________________________________________________
B. Co-Activity Director (Individual who shares responsibility for planning the activity content. For Joint
Sponsor (eg board member or society), this is typically a leadership member from the joint sponsor.)
Name: _____________________________________ Degree (initials): _________________
Affiliation /Dept: ______________________________ Title: __________________________
Address: __________________________________________________________________
City: ____________________________
State: ________ Zip: _____________________
Phone: __________________________
Fax: __________________________________
Email: ____________________________________________________________________
C. Planning Committee Member(s)
Individual(s) responsible for design/content creation of the activity.
Name: ______________________________ ______ Affiliation/Title: _______________________________
Name: ______________________________ ______ Affiliation/Title: _______________________________
Name: ______________________________ ______ Affiliation/Title: _______________________________
Name: ______________________________ ______ Affiliation/Title: _______________________________
Name: ______________________________ ______ Affiliation/Title: _______________________________
D.
Project Manager
Individual responsible for organizing and implementing the activity
Name: _____________________________________ Degree (initials): _________________
Affiliation /Dept: ______________________________ Title: __________________________
Address: __________________________________________________________________
City: ____________________________
State: ________ Zip: _____________________
Phone: __________________________
Fax: __________________________________
Email: ____________________________________________________________________
 Check here if the Project Manager is NOT involved with selecting faculty, topics, and influencing content.
III.
Educational Planning
A. Target Audience (Check all that apply)
NEOMED
Local
Regional
National
International
Anticipated number of participants: ______________________
1. This activity is interprofessional (incorporating two or more disciplines):  Yes
2. This activity is directed to physicians in the following specialties:
No
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
3. This activity is directed to pharmacists in the following specialties:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
4. Other Health Care Professionals (Specify):
__________________________________________________________________________
__________________________________________________________________________
B. Mission
The mission of the Office of Continuing Professional Education is to provide quality educational
activities in an interdisciplinary healthcare environment in order to enhance the knowledge, skills and
performance of physicians, pharmacists and other healthcare professionals in Northeast Ohio.
Which of the following aspects of the Mission Statement is this activity designed to maintain,
develop, or increase? (Check all that apply)
 Knowledge
 Skills
 Performance
C. Desirable Physician Competencies (Not applicable to Pharmacy only programs)
CME activities should be developed in the context of desirable physician attributes. Indicate which
Accreditation Council for Graduate Medical Education (ACGME)/ American Board of medical
Specialties (ABMS) or Institute of Medicine (IOM) core competencies this activity will address:
Core Competencies
Patient-centered care
Interdisciplinary teams
Apply quality improvement
Use informatics
Medical knowledge
Practice-based learning
Interpersonal and communication skills
Professionalism
Systems-based practice
Employ evidence-based practice
ACGME/ABMS
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IOM
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This Activity
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D. Practice Gap and Educational Needs
Gaps in competence, performance, or patients outcome(s) must be identifies in order to establish the
educational needs for the entire activity.
What are your learners not doing now that you want them to be able to do?
_(eg, Using biological therapies for rheumatoid arthritis.)________________________
_____________________________________________________________________
Please describe the professional practice gap(s) driving the need for this activity.
(eg, Rheumatologists are not aware of, or utilizing, novel therapies.)_______________
_____________________________________________________________________
Is this gap in competence, performance, and/or patient outcomes?
E. Evidence Base
Please indicate the evidence base used to identify gap(s). Select all that apply and provide supporting
documentation for each. If you cannot provide supportive documentation, do NOT check that source.
In addition to your expert opinion, select a minimum of 2 additional sources of evidence with supportive
documentation (examples in parentheses).
 Expert opinion of Activity Director.(As documented in your assessment of the practice identified in “D”)
 Judgment of the CE Planning Committee/ Faculty members. (Provide explanatory memo)
 Continuing review of changes in quality of care as revealed by medical audit or other patient care
reviews. (eg, audit report, chart reviews.)
 Formal or informal request or surveys of the target audience, faculty, or staff. (eg summary of
requests or surveys, activity evaluation summaries.)
 Discussion in department meetings. (eg, summary of meeting minutes showing discussion was
related to areas of education need/practice gaps.)
 Medical Guidelines (include reference of source)
 Data from government sources, consensus reports. (eg, government produced documents.)
 New technology, methods of diagnosis/treatment. (eg, description of new procedure, technology,
treatment, etc.)
 Legislative, regulatory, or organizational changes effecting patient care. (eg copy of the
measures/change)
 Joint commission Patient Safety Goals/Competency. (eg, copy of the safety goals and/or
competency)
 Review of professional literature. (eg, citation or abstract of article)
F. Educational Needs (Check all that apply, please select a minimum of one)
 Provide medical/surgical information
 Provide pharmacy information
 Promote appropriate referral
 Demonstrate new techniques to be learned and adopted by the audience for use in their
practice
 Demonstrate new techniques activity participants will not necessarily master but need to
know so that appropriate referral can be considered.
 Provide a review of a subject of field
 Other (Specify): ________________________________________________________
G. Educational Outcomes
What are the expected outcomes of this activity in terms of competence, performance, patient
outcomes (Check all that apply)?
 New Knowledge
 Acquisition of new skills or techniques
 Acquisition of new protocols, policies, and procedures
 Change in pharmacologic management
 Change in diagnostic approach
 More appropriate referral to specialties
 Improve patient outcomes. (Describe): _________________________________________
H. Objectives
Learning Objectives are required to be identified for the activity. These communicate the
expected outcomes of this activity to learners. Please list learning objectives using verbs from
the table below. Indicate the expected outcomes in terms of competence, performance, or
patient outcomes.
Learning Objective
Example: Apply new guidelines in order to provide optimal care
to women with HIV
1
2
3
4
5
6
7
8
9
Competence
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Performance
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




Patient
Outcomes
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Verbs that Measurably Communicate Knowledge, Competence, and Performance
Information
write
count
define
describe
draw
identify
indicate
list
name
point
read
recite
recognize
record
relate
propose
select
tell
state
quote
associate
classify
compare
compute
contrast
describe
differentiate
discuss
distinguish
translate
estimate
explain
express
interpret
locate
predict
report
review
apply
calculate
complete
demonstrate
dramatize
employ
examine
illustrate
interpolate
interpret
operate
order
practice
predict
relate
report
restate
review
schedule
solve
use
utilize
communicate
provide
locate
translate
analyze
appraise
contract
criticize
debate
detect
distinguish
differentiate
diagram
infer
inspect
inventory
question
separate
summarize
highlight
explore
experiment
arrange
assemble
collect
compose
construct
integrate
design
detect
formulate
generate
manage
organize
plan
prepare
prescribe
produce
propose
specify
document
refine
appraise
assess
choose
critique
determine
estimate
evaluate
grade
judge
measure
rate
recommend
revise
score
select
test
rank
internalize
measure
pass
project
empathize
integrate
massage
palpate
know
learn
understand
Comprehension
Application
Analysis
Synthesis
Evaluation
Verbs that impart skills
diagnose
hold
visualize
percuss
Avoid these verbs
appreciate
have faith in
I.
gain knowledge of
Potential Barriers to Practice
Potential barriers need to be addressed within the educational activity as part of the
curriculum. (Check all that apply, please select a minimum of one)
 Lack of time to assess or counsel patients
 Lack of administrative support/resources
 Insurance/reimbursement issues
 Cost
 No perceived barriers
 Lack of consensus on professional guidelines
 Patient adherence issues: (Specify): _______
 Lack of knowledge
 Other barriers: (Specify): ________________
J. Educational Design and Methods
1. Adult learning principles are important to consider when designing the educational
method. Indicate the approaches underlying the proposed activity to ensure that the
format is appropriate for the objectives and desired outcomes of the activity:
Problem-based learning Reflection
Active Participation
Motivation
Commitments to change
Feedback
Reinforcement
2. Indicate the educational methods you plan to use
 Lecture
Case Presentations
Workshops
 Panel Discussions
 Questions & Answers
Cadaver Lab
 Teleconference
 Video/Audio Presentation
 Readings
 Formal Discussion Groups  Educational Poster
 Skills Session
 Audience Response
Simulations (role playing)
 Patient Rounds
 Web-based Interactive  Other Labs
Hands-on workshop with Medical Devices
 Other: _________________________________________________________________
3. Indicate methods by which faculty will be selected (non-NEOMED):
Literature Review
Program Committee/Activity Director Judgment
Past Evaluations
Faculty Recommendation
Medical Society Recommendation Other: ____________________________
4. Solicitation of Abstracts
Will you solicit abstracts for platform presentations at this activity?
 YES  NO
If no, proceed to #5
If yes, will these presentations offer CE credit?
 YES  NO
a. Methods of soliciting abstracts:
_______________________________________________________________________
_______________________________________________________________________
b. Process of peer review and selection
_______________________________________________________________________
_______________________________________________________________________
c. Rules governing publication of papers presented at your meetings.
_______________________________________________________________________
_______________________________________________________________________
5. Are there any proposed faculty employed by a commercial interest?
 YES  NO
If yes, please refer to NEOMED’s commercial interest policy
K: Evaluation
1.
How will you measure change as in section III item G?
___________________________________________________________________________
2.
How will the goal, purpose or expectation of the activity be measured?
 Participant Feedback
 Follow-up Survey of Practice Patterns
 Pre/Post Test
 Patient Outcomes Evaluation
 Other: ____________________________________________________________________
 Include a copy of the evaluation instrument(s)
3.
How ill effectiveness be measured?
Patient Outcomes
 Quality Measures
 Observed Behavior
 Self-Reported Behavior
 Knowledge Expansion
 Other: _______________________________________
 Attitudinal change
L: Accreditation with Commendation Criteria (Physician Only)
1. How will this activity improve professional practice? (C16)
_____________________________________________________________________
2. What additional non-educational strategies (outside of the educational intervention) will be
used to enhance the goal of the activity? Example include laminated cards, screen saves,
chart reminders, stickers, etc. (C17) _________________________________________
______________________________________________________________________
3. Are there any outside factors that have an impact on patient outcomes? If so, what are
they? (c18)
4. Are there any learning barriers such as necessary system or policy change, lack of
time/support, motivations, etc? (C19) Lack of
 Administrative Support/Resources
 Consensus in Professional Guidelines
 Proper Patient Compliance
 Other Resources
 Accessible Venue to Gather New Information/Knowledge
 Other: ______________________________________________________________
5. How are the barriers described above overcome? (C19) _________________________
______________________________________________________________________
6. Are there other initiatives within the institution (NEOMED, joint sponsor, etc.) working on
this issue? (C20)________________________________________________________
______________________________________________________________________
7. What other organizations could you partner with to achieve the goal? _______________
______________________________________________________________________
8. How will this activity impact quality improvement or patient safety at your institution or to
the system framework? (C21) ______________________________________________
______________________________________________________________________
9. How are the scope and content of the activity determined? How involved are NEOMED
faculty in creating scope and content of the activity? (C22) _______________________
______________________________________________________________________
M: ACPE Web Tool Registration Information (Pharmacy Only)
1. Topic Designator:
 Disease State Management/Drug Therapy
 AIDS Therapy
 Law Related to Pharmacy Practice
 General Pharmacy
 Patient Safety
2. Activity Type:
 Knowledge
 Application
 Practice
3. Keywords: (Please select ALL that apply)
 Acne
 Administration
 AIDS
 Alzheimer’s Disease
 Angina
 Anxiety
Acute Pancreatitis
 Adverse Drug Reactions
 Alcoholism
 Ambulatory Care
 Anorexia
 Arrhythmias
 Addiction
 Aging
 Allergies
 Anemia
 Anticoagulation
 Arthritis
 Asthma
 Atherosclerosis
 Atrial Flutter
 ADHD
 Benign Prostatic Hypertrophy  Billing
 Biotechnology
 Bipolar Disorder
 Burns & Scalds
 Calculations
 Cardiology
 Cardiovascular Disease
 Certification
 Chronic Kidney Disease
 Cirrhosis
 Clinical Decision Support
 CDTM
 Common Cold
 Community-Acquired Pneumonia  Compounding
 Constipation
 Cont. Professional Development
 Coronary Heart Disease
 Cough
 Critical Care
 Crohn’s Disease
 Cultural Diversity
 DVT
 Depression
 Dermatitis
 Devices
 Diabetes (DM)
 Diarrhea
 Diversity
 Drug Diversion
 Drug Dosing
 Drug Information
 Drug Interactions
 Drug Overdose
 Drug Use Evaluation (DUE)
 E-prescribing
 Eczema
 Electrolyte Abnormalities or Electrolyte Management
 Emergency Medicine
 End of Life
 Environmental Aspects
 Epilepsy
Ethics
 Evidence-based Medicine
 FDA
 Gastroenterology
 Geriatrics
 Glaucoma
 Gynecology
 Headache
 Heartburn
 Hematology
 Hepatitis
 Hepatology
 Herpes
 HIPAA
 Hypercholesterolemia
 Hyperglycemia
 Hypertension
 Hyperuricemia
 Importation
 Infectious Disease
 Inflammatory Bowel Disease  Influenza
 Insomnia
 Inventory Control
 JCAHO
 Laboratory
 Leadership
 Long-Term Care
 Management
 Marketing
 Medical Errors
 Medical Record
 Medication Delivery System  Medication Disposal
 Medication Safety
 MTM
 Meningitis
 Menopause
 Metabolic Disorders
 Migraine
 Multiple Sclerosis
 Myocardial Infarction
 Nausea
 Neonatology
 Neurology
 Neutropenia
 New Drugs
 Non-compliance
 Nutrition
 Obesity
 Oncology
 Ophthalmology
 Orthopaedics
 Osteoarthritis
 Ostomy
 Outcomes
 Pain Management
 Parkinson’s Disease
 Pelvic Inflammatory Disease  PAD
 Atrial Fibrillation
 Automation
 Bioequivalence
 Brain Injury
 Cancer
 Cerebrovascular Disease
 COPD
 Clinical Trials
 Communication
 CHF
 Coronary Artery Disease
 Counseling
 Cultural Competency
 Dementia
 Dermatology
 Dialysis
 Documentation
 Drug Enforcement Administration
 Drug Manufacturing
 Dyslipidemia
 Education
 Embolism
 Endocrinology
 Erectile Dysfunction
 Fever
 GERD
 Gout
 Health Literacy
 Hemorrhoids
 Herbal Medicine
 HIV
 Hyperlipidemia
 Immunizations
 Infertility
 Informatics
 Irritable Bowel Syndrome
 Law
 Managed Care
 Medicaid
 Medicare
 Medication Errors
 Men’s Health
 Mental Health
 Monitoring
 National Guidelines
 Nephrology
 Neutropenia
 Nuclear
 Obstetrics
 Order Entry
 Osteoporosis
 Pain
 Pediatrics
 Pharmaceutical Care
 Pharmocoeconomics
 Pharmacy Calculations
 Polypharmacy
 Premenstrual Syndrome
 Psychiatry
 Pulmonary Disease
 Radiology
 REMS
 Resistance
 Rheumatoid Arthritis
 Safety
 Seizure
 Shock
 Skin Disorder
 Smoking Cessation
 Sterile Compounding
 Substance Abuse
 Surgery
 Technology
 Terrorism
 Thyroid Disease
 Transplantation
 Ulcers
 Urology
 Ventilation
 Weight Mgmt
 Workplace Issues
4.
 Pharmacogenomics
 Platelet Disorders
 Precepting
 Preventative Medicine
 Psychology
 Pulmonary Embolism
 Regulation
 Renal Disease
 Restless Leg Syndrome
 Rhinitis
 Schizophrenia
 Sexual Dysfunction
 Sickle Cell Disease
 Sleep Apnea
 Spanish Language
 Stevens-Johnson
 SIDS
 Systemic Lupus (SLE)
 Telemedicine
 Third Party Payers
 Toxicology
 Trauma
 Uremia
 USP Chapter 797
 Veterinary Medicine
 Withdrawal
 Wound Healing
 Pharmacokinetics
 Pneumonia
 Pregnancy
 Psoriasis
 Psychotherapy
 Pulmonary Hypertension
 Reimbursement
 Research
 Restricted Drug Distribution
 Safety
 Sedation
 STD
 Sinusitis
 Smallpox
 Sports Medicine
 Stroke
 Sunburn
 Teaching
 Telepharmacy
 Thrombosis
 TIA
 Ulcerative Colitis
 Urinary Incontinence
 Varicella Zoster Virus
 Viral Infection
 Women’s Health
Drug/Devices: (Please select ALL that apply)
 Abortifacients
 Acne Products
 Aldosterone Receptor
 Alpha Adrenergic Agonists  Alpha-1 Receptor Agonist
 Alpha-Glucosidase Inhibitor
 Alpha/Beta-Adrenergic Blocking Agents  Aminoglycosides
 Analgesics
 Androgens
 Anesthetic Agents
 ACE Inhibitors
 Anorexiants
 Antacids
 Antiarrhythmic Agents
 Antiarthritic Agents
 Antiasthmatic Agents
 Antibacterial Agents
 Antibiotics
 Anticholinergic Agents
 Anticoagulant Agents
 Anticonvulsant Agents
 Antidepressant Agents
 Antidiabetic Agents
 Antidiarrheal Agents
 Antiemetic Agents
 Antiepilectic Drugs (AED)
 Antifungal Agents
 Antihistamines
 Antihyperlipidemic Agents
 Antihypertensive Agents
 Antimalarial Agents
 Antimicrobial Agents
 Antineoplastic Agents
 Antiobesity Agents
 Antiparasitic Agents
 Antiplatelet Agents
 Antipsychotic Agents
 Antipyretic Agents
 Antiretroviral Agents
 Antispasmodic Agents
 Antithrombotic Therapy
 Antiviral Agents
 Appetite Suppressants
 Beta-2 Agonists
 Beta-Adrenergic Blocking
 Beta-Blockers
 Beta-Lactamase Inhibitors
 Bisphosphonates
 Bronchodilators
 Calcium Channel Blocking
 Carbapenems
 Cephalosporin & Related Products  Chemotherapy
 Cholesterol Lowering Agents  Cholinergic Agents
Cholinesterase Inhibitors
 Clotting Factors
 Clycoprotein IIb/IIa Blockers
 Colony Stimulating Factors
 Contraception
 Controlled Substances
 Corticosteroids
 COX-2 Inhibitors
 Cytokines
 DDP-IV Inhibitors
 Decongestants
 Delivery Systems & Devices
 Diagnostics
 DMARDs
 Diuretics
 Dopamine Agonists
 Estrogen Receptor Antagonists  Estrogens
 Fibrinolytics
 Fluoroquinolones
 Glucose Monitoring Devices
 Gonadotropin-releasing Hormone
 Growth Hormone Receptor Antagonists
 H2- Receptor Antagonists
 Herbal Medications
 Herbal Supplements
 Histamine Antagonists
 Hormones
 Immune Globulin
 Immunomodulators
 Immunosuppressive Agents  Immunotherapy
 Impotence Agents
 Incretin Mimetics
 Inhalants
 Inotropes
 Insulin
 Insulin Delivery Systems
 Interferons
 Investigational agents
 Laxatives
 Leukotriene Receptor Antagonists
 Low Molecular Weight Heparins  Macrolides
 MAO Inhibitors
 Monoclonal Antibody
 Narcotics
 Nasal Decongestants
 Nicotine Replacement
 Nitroglycerin
 NSAIDs
 Noradrenergic Agents
 Opiates
 Opioids
 Opthamalics
 Oral Contraceptives
 Over-the-Counter Products
 Over-the-Counter Treatment  Penicillins
 Phosphodiesterase Inhibitor
 Progestins
 Protease Inhibitors
 Proton Pump Inhibitors
 Quinolones
 Radiopharmaceuticals
 Salicylates
 Sedatives & Hypnotics
 SSRI
 Self Monitoring Devices
 Skeletal Muscle Relaxants  Statins (HMG-COA) Reductase Inhibitors
 Stimulants
 Stool Softeners
 Sulfonamides
 Testosterone
 Tetracyclines
 Thrombolytic Agents
 tPA
 Topical Agents
 Unfractionated Heparins
 Uricolytic Agents
 Uricosuric Agents
 Vaccines
 Vasodilators
 Vitamins
 Xanthine Oxidase Inhibitors
IV.
Finances
A. Name of the Fundraiser(s)
Identify individual(s) involved in fundraising for this activity.
B. Grants (Refer to Commercial Interest Policy)
1. Will educational grants be solicited? (monetary or other)
 YES
 NO
If yes, how many funding sources do you anticipate?
 One grantor
 Two or more grantors
2. Do you anticipate receiving in-kind grants for the activity? (medical supplies)
 YES
 NO
If yes, what type? _____________________________________________
C. Exhibits (Refer to Commercial Interest Policy)
Will this activity have exhibit space?
 YES  NO
If yes, describe plan? __________________________________________
D. Authorized Individuals
1. Identify individual(s) authorized to approve expenditures for this activity:
Name_____________________________ Title_____________ Phone: _____________
E. Budget
Proposed Budget- Required for all Activities
Please complete a proposed budget. A template is available from OCPE, if needed.
Honoraria
Are you budgeting honorarium for:
Outside Faculty:  YES  NO
NEOMED Faculty (please refer to suggested honoraria):  YES
 NO
F. Account/Department Information
NEOMED Department account name and number to transfer activity net margin or charge net
loss/profit or complete cost transfer for joint sponsor/managed program fees:
Account Name: __________________________ Account Number: _____________________
V.
Document Checklist
The following must be submitted along with the completed CE Application:
 Activity Director (s) Disclosure
 Planning Committee Disclosure
 Project Manager Disclosure
 Budget, including all revenue and expenses
 Fundraising Plan, including grants, exhibits, and other promotional items
 Copyright Form
 Signed Letter of Agreement for Joint Sponsors or Letter of Agreement for managed programs
 Signed Activity Director’s Agreement
 Supporting documentation for Evidence Base(s)
 Agenda with total hours requesting