CME ACCREDITATION REQUEST FORM

 CARIBBEAN COLLEGE OF FAMILY PHYSICIANS CME ACCREDITATION REQUEST FORM (APPENDIX 12)

19a Windsor Avenue, Kingston 5 Jamaica Website: www.ccfpjamaica.com/ Member of the World Organization of Family Medicine National Colleges and Associations (WONCA) Please note that a separate application is required for each day and application must be submitted at least one (1) month prior to the event. (APPROVED BY THE CARIBBEAN COLLEGE OF FAMILY PHYSICIANS - CCFP)

For a downloadable PDF version of this form, please click here.
NAME OF CONTACT:
NAME OF CONTACT:
First
Middle
Last
(please indicate if you are requesting a meeting or session accreditation only)
(please indicate if you are requesting course accreditation only)
ACCREDITATION REQUEST FOR:

Maximum file size: 67.11MB

(if file cannot be uploaded, please email to ccfpjachapter1988@gmail.com

Maximum file size: 67.11MB

(if file cannot be uploaded, please email to ccfpjachapter1988@gmail.com)

Maximum file size: 67.11MB

(if file cannot be uploaded, please email to ccfpjachapter1988@gmail.com)
DESCRIPTION OF EDUCATIONAL METHODOLOGY TO BE USED:
METHOD OF PROGRAMM EVALUATION:
REQUESTING ACCREDITION THROUGH (Accrediting Body)
WEBINARS/MEETINGS ONLY/HYBRID – CME/WEBINARS/MEETING ACCREDITATION – I understand that there is an administrative cost for processing this application. Application for Chapters (in good standing) is US$150.00 per day: Affiliates of CCFP/Other Chapter- US$200.00 per day. Application for Non-Affiliates is US$300.00 per day. There is an additional cost for the Medical Council of Jamaica (if accreditation is required for Jamaican Physicians of J$7,500.
ONLINE/ON DEMAND/COURSE CME/ACCREDITATION -I understand that there is an administrative cost for processing this application. Application for Chapters in good standing is US$300.00: Affiliates/Other Chapters is US$500.00. Application for Non-affiliates is US$800.00.
PLEASE NOTE: PAYMENT INFORMATION (Cheque made payable to the Caribbean College of Family Physicians or Direct Deposit to A/C#331001678, NCB, Account type: JMD Business Chequing Account; or USD S/A 33400762. Branch is Manor Park or Constant Spring Financial Centre. You can contact us for other options to pay. An estimate will be provided upon receipt of your application.
The Applicant is responsible for distribution of CME Certificates to attendees
A list of the attendee is to be provided to the CCFP at the end of the event
MEETING/CME ACCREDITATION ONLY: The applicant is responsible for designing its own promotional flyer, email CME Certificates to attendees and promoting event (if you require the CCFP to design flyer and promote event and email certificates to attendees please indicate), as these attract additional costs
ONLINE/HYBRID/ON DEMAND CME ACCREDITATION ONLY: The applicant is responsible for designing and promoting it online/on demand course. Applicant are to ensure that the signed CME Certificates for the attendees can be downloaded by each participant after completion of the course. (For promoting the online/on demand course an additional cost will be applicable.
The Caribbean College of Family Physicians (CCFP) classifies organizations into Affiliates and Non-Affiliates to distinguish the nature of our collaborations
Administrative Cost for Services are as follows. Please indicate that which is applicable
Cost for additional Services are as follows. Please indicate that which is applicable
Certificate Issuance: Administrative cost/fees include the emailing of up to 100 CME Certificates of Completion via our platform. For events requiring the emailing of more than 100 certificates, an additional fee of US $195 or J$ equivalent will apply. Requests for certificate emailing must be indicated at the time of application submission on our website.. Please indicate that which is applicable