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)
:
Target Audience(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 whether the entire educational activity should be accredited, requiring participants to attend all activities occurring at the event from beginning to end. If each activity should be accredited individually, the Faculty Agreements from presenters must accompany the application. If accrediting the entire event as one activity, you can include Learning Objectives and Topic Designator below. If you do not, they must be included on the Faculty Agreements. Presenter Faculty Agreements are still required for events accredited as one activity.
Accreditation – Event or Activity
If accrediting as one activity, please select whether the activity is knowledge -based or application-based. (Only complete if accrediting as one event).(Required)
If accrediting as one activity, please select whether the activity is knowledge -based or application-based. (Only complete if accrediting as one event).
Program should be accredited for the indicated Topic Designator (select one only if accrediting as one event):

Learning Objectives

A minimum of three are required. Only complete if accrediting as one event.
*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 send you a link to an activity announcement flyer. The activity announcement will include all the ACPE required information, such as the UAN, the credit hours of the activity, the type of program (knowledge or application based) and the learning objectives for the target audience. Should you choose to use this as your announcement, you can either provide your participants with the activity announcement link, or you can copy the announcement information and save as a PDF file. If your event is also being accredited for by other health care disciplines, you will be required to create your own promotional pieces. In addition, if you choose to create your own activity announcement, rather than using the link provided for you by MPA, you will need to submit your promotion pieces to MPA for approval at least 30 days prior to the event/activity date and BEFORE distribution for review to verify that all ACPE requirements are being met. In this case, refer to the activity announcement checklist (Appendix 2 in the Joint Providership Manual Instructions) for items that need to meet accreditation criteria.

Registration Form

Complete only if you hire MPA to coordinate and process registration (request support staff contract)
MM slash DD slash YYYY
Mailing address to which registration fees (minus service fees) should be mailed:
Registration Rate(s): Indicate the fee that attendees are expected to pay

Pharmacist Member
One-day Rate
Two-day Rate
One-day Rate if Registering After Deadline
Two-day Rate if Registering After Deadline
Pharmacist Nonmember
One-day Rate
Two-day Rate
One-day Rate if Registering After Deadline
Two-day Rate if Registering After Deadline
Technician Member
One-day Rate
Two-day Rate
One-day Rate if Registering After Deadline
Two-day Rate if Registering After Deadline
Technician Nonmember
One-day Rate
Two-day Rate
One-day Rate if Registering After Deadline
Two-day Rate if Registering After Deadline
Refunds

Supporters: List the organization(s) that should be recognized as event supporters

Assistance

Indicate the person to whom individuals should contact if questions about this event arise
Assistance Name(Required)

Schedule of Educational Activities

Please provide an agenda with timeline, including breaks, meal functions, and PCE activities, for this event. An agenda is required even if the Hosting Organization must create its own brochure. See Example A for an example agenda.
Select

Terms of Agreement - Hosting Organization

The Hosting Organization agrees to complete the following assignments and adhere to established deadlines.
Assignment Deadline
Submit to MPA completed joint providership agreement with $50 application fee (payable to MPA) Minimum 45 days prior to
Submit to MPA completed faculty agreements for each speaker/author Minimum 45 days prior to event
If the Hosting Organization is completing the flyer, a draft must be submitted to MPA Minimum 30 days prior to event
Distribute announcement/promotional material provided by MPA to prospective attendees (if Hosting Organization is preparing its own announcement, it must be reviewed and approved by MPA at least 30 days prior, and before distribution) Minimum 30 days prior to event
Submit to MPA PowerPoint slides, handout, outline, references or key points for each activity (see Example B for outline, references and key points example) Minimum 15 days prior to event
Submit to MPA multiple-choice posttest questions, answers and feedback explaining why chosen answers are correct for each activity (see the faculty agreement [Appendix 1] for the number of required posttest questions Minimum 15 days prior to event
Submit to MPA case studies and/or other supplemental materials used in each activity for accreditation records Minimum 15 days prior to event
Distribute to pharmacist and pharmacy technician participants MPA- provided instructions on how to earn continuing education credit Onsite prior to event
Disclose to participants potential faculty conflicts of interest as provided by MPA Onsite prior to event
Submit to MPA completed form that measures achievement and impact of activity on MPA's mission (see Appendix 5) Maximum 15 business days post event
Provide activity evaluation summary to faculty Maximum 30 days post event

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.
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 provide Hosting Organization with a link to the activity announcement with will contain all ACPE required activity information Maximum 35 days prior to event
If MPA staff will serve as faculty, collect completed faculty agreement, including contact information, activity details, CV and biography, educational needs assessment, learning objectives, activity type, disclosure, and compensation Maximum 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 statement for each activity and submit to Hosting Organization Maximum 10 days prior to event
Provide Hosting Organization with sum of online activity evaluations and posttests Maximum 30 days post event
Invoice Hosting Organization for fees due Maximum 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, including the joint providership agreement and introduction to joint providership document. 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)
Please forward along this Faculty Agreement Link to your presenters. Thank you.
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