Continuing Pharmacy Education Activity Application Form 4430

If this is your first time to fill out this form or if you have questions about any of the information requested below, please see the "Speaker Guide."

All materials must be submitted no later than 15 days prior to educational activity date in order to file for continuing pharmacy education (CPE) credit with the Accreditation Council for Pharmacy Education (ACPE).

Asterisk (*) indicates a required field.

Primary Contact Information

First Name*

Middle Initial

Last Name*

Email Address*

Phone Number*

St. Jude Mail Stop or Address*

General Activity Information

Title of presentation*

Sponsoring Department*

Presenter*

Presenter credentials/title*

Name of meeting or event (e.g., monthly staff / journal club)*

Activity Place, Date, and Time

Location of activity*

On campus Off campus

Full Address*

Date of activity*

Time of Activity

Hour*

Minute*

AM or PM*

AM PM

Please choose the total time allotted for this CPE activity (including questions)*

15 Minutes 30 Minutes 45 Minutes 60 Minutes

Activity Objectives

List activity objectives (Pharmacists)

Objective #1*

Objective #2

Objective #3

Objective #4

List activity objective (Pharmacy Technicians) (must be different from those of Pharmacists if this is a joint activity)

Objective #1

Objective #2

Objective #3

Objective #4

Type of Activity

Activity format*

Activity materials will be*

Knowledge Based Application Based Practice Based

Please briefly state why this topic was chosen and the rationale for conducting the education*

Activity Key Words

Active Learning

Select the types of active learning that will be incorporated with this activity and please upload a copy with correct answers included (check all that apply)*

Pre/post test assessments Upload

Audience response questions Upload

Debate Upload

Muddiest point Upload

Trivia games Upload

Role play Upload

Matching Upload

Memory matrix Upload

Other Upload

I agree to share this information with St. Jude*
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