Continuing Education Program Approval Form - Minnesota Board Of Pharmacy Page 2
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27.
Was a needs assessment done?
______ Yes
______ No
If yes, indicate how the educational needs were assessed in the planning for this program by
checking the appropriate blank:
______
A survey conducted among potential clientele.
______
The program was planned with pharmacist representatives.
______
Other methods were employed.
Please describe briefly.
__________________________________________________________________________________________
__________________________________________________________________________________________
8.
Program Goals: ____________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
9.
Program Learning Objectives: ______________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
10. How will the program be presented?
(e.g., Lecture, panel, discussion group, workshop,
group study session, private study, etc.)
__________________________________________________________________________________________
__________________________________________________________________________________________
11. What types of audio/visual aids will be used?
(Please check those which are applicable.)
______ Slides
______ Films
______ Video tapes
______ Charts
______ Exhibits
______ Audio cassette tapes
______ Other (describe) ___________________
12. Will program outlines be made available to participants?
______ Yes
______ No
13. Will case histories be used in the program?
______ Yes
______ No
14. Will an annotated reading list be made available?
______ Yes
______ No
15. PROGRAM FACULTY & QUALIFICATIONS:
Name: _________________________________
Position: ____________________________________
_________________________________
____________________________________
_________________________________
____________________________________
16. Describe the methods to be used in evaluation of this program in terms of procedures,
__________________________________________________________________________________________
__________________________________________________________________________________________
17. OTHER INFORMATION WHICH YOU MAY WISH TO RELATE: ___________________________________________
__________________________________________________________________________________________
18. Please enclose promotional brochures, program schedule, materials, outlines, etc.
_______________________________________________________________________________________________
Person completing this form/title
Telephone number
Cody C. Wiberg
Please return this completed form to:
Executive Director
MN Board of Pharmacy
2829 University Ave. SE, #530
Minneapolis, MN
55414-3251
Phone (651) 201-2825
10\96
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