Complete this form if event consists of more than one activity and you are: ACCREDITING THE ENTIRE PROGRAM AS ONE.

Complete this agreement and submit it to Michigan Pharmacists Association (MPA) a minimum of 45 days prior to the activity date. This joint providership agreement between the MPA and the Hosting Organization defines the relationship between the two parties regarding the activity or event listed below and is consistent with standards for continuing pharmacy education.

Hosting Organization Information

Please provide contact information for the person responsible for this event or activity. To avoid confusion and to maintain efficiency, please appoint only one point-of-contact.
Name of Contact(Required)
Mailing Address(Required)
ACPE Accredited Proivder(Required)

Activity Information

Please provide information about the activity
MM slash DD slash YYYY
Time(Required)
:
Program Format(Required)

Accreditation

MPA will accredit programs for pharmacists and/or pharmacy technicians based on the targeted audience identified above. If more than one activity (a.k.a. program, session) is being offered at a single event, please indicate whether each activity should be accredited individually, allowing participants to select the activities they wish to attend, but not requiring them to attend every activity; or if the entire educational activity should be accredited, requiring participants to attend all activities occurring at the event from beginning to end.

This is for events being accredited in their entirety as one event or bloc of credits. Should you want your program activities accredited individually, please fill out the Joint Providership - Individual Accreditation form.

If accrediting as one activity, please select whether the activity is knowledge-based or application-based.(Required)
If accrediting as one activity, please select whether the activity is knowledge-based or application-based.
Program should be accredited for the indicated Topic Designator (select one only if accrediting as one event):(Required)

Educational Needs Assessment and Gaps in Knowledge

Faculty, along with the organization hosting the continuing education activity, should identify the problem or clarify the need (gaps in knowledge), the current state of pharmacy practice and the desired state of pharmacy practice. This should be evidence-based facts, rather than assumptions, and should be used to formulate what should be learned in order to move the learners from their current state of practice to the desired state and assist in developing learning objectives. References and citations should be provided where appropriate.
What is the problem (potential or actual) that needs to be addressed? Or, what new process or procedure (current or future), recent change or expected changes are happening that will affect this group?
What is the audience doing now that could or has led to this problem based on facts, rather than assumptions? Provide references or citations. Or, where is the audience currently in this skill, training, process or procedural aspect?
What should or could the audience be doing instead to solve or prevent this problem? Or, what information, skill or technique will the audience need to attain in order to implement this new process or procedure?

Learning Objectives

Michigan Pharmacists Association (MPA) will attempt to accredit your program for pharmacists and pharmacy technicians by following the ACPE accreditation standards. Programs that benefit pharmacists and pharmacy technicians must have specific and separate learning objectives for each audience. If your pharmacy continuing education activity (PCE) benefits only pharmacists, only pharmacy technicians or both, please complete the appropriate learning objective section below. See guidelines on how to develop specific and measurable learning objectives. MPA must approve learning objectives. This PCE activity will include discussion of off-label use:
PCE Off-Label Use
This PCE will include discussion of off-label use.
Targeted Audience(Required)

Pharmacist Learning Objectives

A minimum of three objectives are required. The majority of the objectives should be structured to meet identified educational gaps in knowledge that will move learners to a desired state of practice. At the end of this activity, participants should be able to:

*Select an approved verb from the drop down menu

Pharmacy Technician Learning Objectives

(if applicable)

A minimum of three objectives are required. The majority of the objectives should be structured to meet identified educational gaps in knowledge that will move learners to a desired state of practice. At the end of this activity, participants should be able to:

*Select an approved verb from the drop down menu
Activity Announcement Content
To ensure all ACPE requirements are met according to the standards for continuing pharmacy education, MPA will provide you with an activity announcement link with all ACPE required information. Please be sure to include this link or all ACPE required information on all of your marketing materials and registration page.
Registration Rate(Required)
ACPE now requires MPA to gather registration rate information. Does this activity require a fee for participation?
Registration Type

Terms of Agreement - MPA

The responsibility for assurance of all ACPE criteria rests solely with the Provider; therefore, MPA will be responsible for the following. Note: Business days are Monday through Friday.
Assignment Deadline
Notify Hosting Organization of MPA's intent to accredit PCE activity Maximum 7 business days after receipt of joint providership agreement
MPA will will accredit the program a minimum of 35 days before the event Minimum 35 days prior to event
MPA will provide Hosting Organization with an activity announcement link, which will contain all program and ACPE information Minimum 35 days prior to event
Prepare evaluations and posttests for each activity and submit program instruction sheet to Hosting Organization Maximum 10 days prior to event
Prepare faculty conflicts of interest/speaker disclosure statement for each event and submit to Hosting Organization Maximum 10 days prior to event
Monitor LMS and work with Hosting Organization to ensure participants can claim CE credit Up to 60 days post-event
Provide Hosting Organization with a summary of evaluations and post-tests, if requested by host Minimum of 60 days post-event
Invoice Hosting Organization for fees due Minimum 60 business days post event
Maintain all records Records will be kept a maximum of six years
On behalf of the Hosting Organization, I agree to adhere to the guidelines and terms of agreement set forth in the joint providership manual, agreement and all supplemental materials. I recognize that MPA may terminate this agreement should documentation not be submitted on time and if any activity appears to be in conflict with MPA's commercialism policy and mission. Moreover, MPA has the authority to decline providing continuing education credit to any participant not meeting attendance requirements set forth.
This is an electronic signature(Required)
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