Continuing Education Program Approval Form - Minnesota Board Of Pharmacy
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1
2Show name and address where
FOR OFFICE USE ONLY
APPROVED ____ hrs.
reply should be sent if different
CE Credit
from that shown below:
DATE: _______________
________________________________________
BY: _________________
________________________________________
Date
Continuing Education
Received _____________
Advisory Task Force
________________________________________
(651) 201-2825
MINNESOTA BOARD OF PHARMACY, 2829 University Ave. SE, #530, Minneapolis, MN 55414
CONTINUING EDUCATION PROGRAM APPROVAL FORM
DESCRIPTION: The program provider is directed to follow the guidelines in completing this form.
Incomplete forms may be returned for further information delaying program
reviewal and reply.
To receive credit, the form must be submitted prior to the
program/course.
1.
Name and address of organization or individual seeking approval:
1A) Date of application
_______________________________________________
_______________________
_______________________________________________
_______________________________________________
2.
Name & address of individual responsible for continuing education program where this
differs from #1:
__________________________________________________________________________________________
__________________________________________________________________________________________
3.
As a program provider do you agree to:
YES
NO
(a)
maintain attendance records for this program?
______
______
(b)
include name and address of participants on attendance records?
______
______
(c)
maintain attendance records so that % completion or hours
completed will be shown?
______
______
(d)
provide evidence to each participant of satisfactory completion of
the program?
______
______
(e)
make such attendance records available on request to participants
or board for three years after completion of program?
______
______
4.
Do you agree to:
(a)
maintain description of content of this program?
______
______
(b)
make program description available to participant or board for
three years after completion of last program presentation?
______
______
(c)
submit a copy of a summary of the evaluation results if requested
to do so?
______
______
5.
PROGRAM TITLE: ____________________________________________________________________________
6.
DESCRIPTION OF PROGRAM:
(a)
Program site(s): ____________________________________________________________________
(b)
Program date(s) where applicable: ___________________________________________________
(c)
Number & length of program units (where applicable) _________________________________
(d)
Type: (seminar, corres., etc.) ______________________________________________________
(e)
Duration of total program:
(for seminar, study group, etc.) _______________________________ contact hours
(for self-study programs)
_______________________________ estimated study time
(f)
Nature of audience for whom program prepared ________________________________________
__________________________________________________________________________________________
(g)
Number of participants anticipated: _________________________________________________
- O V E R -
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