AAAAI Educational Activity Proposal

Title of Activity *

AAAAI Constituency *

What group, has initiated this program? Please specify any constituency involvement including Leadership Institute, committees, interest sections, taskforces, workgroups, etc. who are involved in this activity. List “N/A” if not applicable.

Primary Contact Name *

Primary Contact Email *

Primary Contact Phone *

Activity Type *

Select One:

Credit Type Applying for *

CME (Physician)

CE (Nurse)

Is this webinar a stand alone activity or part of a series *

Part of a webinar series

Stand alone webinar

Has the series already been approved for CME/CE *

Yes

Activity Start Date *

Month

Day

Year

Activity End Date *

Month

Day

Year

Date of Live Webinar *

Month

Day

Year

Registration

Will you be using AAAAI's LMS for registration *

Yes

Please detail the registration fee breakdown for your activity

Member Physicians, Non-Member Physicians, Allied Health, etc.

Are you wanting to make a recording of this webinar available for CME/CE after the live date? *

Yes

Are there additional questions/information that you need to gather during registration

Do you need to know of diet restrictions, guests, special event attendance, etc. Please describe in detail.

Start Time of Live Webinar (Central Time) *

End Time of Live Webinar (Central Time *

Desired Registration Open Date

Month

Day

Year

Desired Registration Close Date

Month

Day

Year

Description *

This field is copied directly into the registration and credit claiming site. Please provide an engaging and grammatically correct paragraph as this will be the first thing potential registrants will see.

Activity Location Name

e.g. a place of business, venue, meeting point

Activity Location Address

Full street address required.

Target Audience *

Examples: A/I Physicians, Primary Care Physicians, Fellows-in-Training, Residents & Medical Students, Nurses, NPs, PAs, Dietitians, CRTs/RRTs, Researchers, Practice Managers, etc.

Total Estimated Audience

Anticipated # of Physicians

Anticipated # of Nurses

Anticipated # of Other

Names of Planning/Steering Committee *

List the planners of this activity. Please be sure to list full names and credentials.

Moderator(s) Name *

Please be sure to list full names and credentials

Names of Presenting Faculty *

List all individuals who will be presenting content, leading discussions or demonstrations, etc. Please be sure to list full names and credentials.

Names of Course Authors *

Please limit to 6 or fewer people

Will faculty be paid an honorarium *

Yes

Please list the honorarium amount and how you determined it.

Needs Assessment & Learning Objectives

Please let us know if the topic of the activity you are requesting aligns with the AAAAI Needs Assessment, as outlined in the most recent Education Needs and Practice Gaps document.

Priority will be given to projects that address a learning gap listed in the most recent AAAAI Needs Assessment.

Is this topic listed on the current AAAAI Needs Assessment? *

Yes

Please describe how this activity addresses this learning gap from the AAAAI needs assessment. *

Please indicate why you selected the topic(s) chosen for your activity, including references where needed. Please be specific. *

What do you want your learners to take away from this activity? *

These will be your learning objectives. Please submit at least one per talk/topic, keeping the following statement in mind: Upon completion of this activity, participants should be able to...

Funding

Has funding already been secured to support the development of this activity? *

Yes

Please identify the source(s) of the funding and amount. *

Do you wish to apply for Commercial Support for this activity *

Yes

Please list the name of the companies and the amount to request

What is the topic of your podcast *

Who is your suggested guest with one alternate? *

What are 3-5 learning objectives or specific areas related to the topic? *

Zoom Link & Details *

Paste the zoom invitation text for the webinar here.

Additional documents

Agenda *

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx ppt pptx xls xlsx xml.

Course Outline *

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx ppt pptx xls xlsx.

Additional Document #1

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx ppt pptx xls xlsx.

Additional Document #2

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx ppt pptx xls xlsx.

Estimated Budget

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx ppt pptx xls xlsx.

Leave this field blank

AAAAI Education Center

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For instructions on how to use this form, including timelines and templates, please visit https://education.aaaai.org/cmeinfo.

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AAAAI Educational Activity Proposal

For instructions on how to use this form, including timelines and templates, please visit https://education.aaaai.org/cmeinfo.