IMQ Demographic Information Form
A Subsidiary of the California Medical Association
Demographic Information Form for CME Programs
This Demographic Information Form must be completed and submitted via e-mail to
CMEAccreditation@imq.org by the due date assigned to your cohort. Please put “Demographic
Information Form” in the subject line of your email.
1. Name of applicant organization as it appears on CME accreditation certificate:
2. Organization or CME Program Website:
3. Contacts
Primary Contact (i.e., CME Coordinator)
Note: Please list the name and contact details for the person who will be your organization’s primary
contact for communicating with IMQ.
Name
Title
Address
Telephone
Fax
E-mail
CME Chair or Physician with Primary Responsibility for CME Program
Name
Title
Address
Phone
Fax
E-mail
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IMQ Demographic Information Form
Chief Executive Officer, President or Executive Director
Name
Title
Address
Telephone
Fax
E-mail
4. Survey preferences
a. Please identify preferences for your onsite survey:
b. Date range or days of the week:
c. Time of day:
d. Address:
5. Type of Organization
Please check the category that most accurately describes your organization and provide details related
to the category you select.
Category
Details
__Hospital/Medical Center
Number of physicians on Medical Staff:
Number of licensed beds:
Number of facility sites:
Is your hospital/medical center part of a healthcare system:
Yes No
If Yes, name of the system:
__Multi-organization CME Provider (two or more organizations accredited as a single CME provider;
includes CME Consortia)
List each facility site and its
Number of physicians
Types of
Estimated or actual
location (add rows as needed) practicing
activities to be
number of activities to
conducted
be conducted annually
__Non Profit Physician
membership organization
__Non Profit (Other)
__Healthcare Insurer or
Manage Care Company
© IMQ 2014
Number of physician members:
Please specify type of organization:
Number of physicians represented by your organization:
Number of physicians in network:
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IMQ Demographic Information Form
__Publishing/Education
Company
Please specify relevancy to CME:
__Government or Military
Please specify relevancy to CME:
__Not Classified
Please specify type of organization:
6. Please list names of individuals involved in the routine planning and/or approval of CME activities,
such as the CME Committee Chair, Committee Members, and Coordinator.
Name
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Title/Specialty
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