Joint Providership Agreement – Individual Accreditation

Complete this form if event consists of more than one activity and you are: ACCREDITING ACTIVITIES INDIVIDUALLY.

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)

First Last

Hosting Organization(Required)

Mailing Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Email Address(Required)

Phone Number(Required)

ACPE Accredited Proivder(Required)

The Hosting Organization is not an ACPE-accredited provider.

The Hosting Organization is a fellow ACPE-accredited provider, and its four-digit ACPE provider identification number is: (provide number below)

ACPE Provider Identification Number (if applicable above)

Activity Information

Please provide information about the activity

Event or Activity Name(Required)

Date(Required)

Time(Required)

Location(Required)

Target Audience(Required)

Pharmacists

Technicians

Students

Program Format(Required)

Live, In-person

Live, Virtual

Home Study

Video Recording

Other

Accreditation

MPA will accredit programs for pharmacists and/or pharmacy technicians based on the targeted audience identified above. If the event has more than one activity (a.ka. program, session) being offered at the event, you can choose to have activities accredited individually, allowing participants to select the activities they wish to attend, but not requiring them to attend each activity; or the entire education activity can be accredited as one program, requiring participants to attend all activities occurring at the event from beginning to end. This application is for events being accredited individually. Should you want your program activities accredited in their entirety as one program, please select the appropriate application.

Activity Announcement Content

To ensure that 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.

The Hosting Organization agrees to include activity link or all ACPE information in advertising and/or registration

Registration Rates(Required)

ACPE now requires MPA to gather Registration rate information Rate(s): Does this activity require a fee for participation?

Yes

Registration Type

Registration: A one-time charge

Subscription: A recurring fee, typically monthly or annually

Membership: A regular payment to be part of an organization

Terms of Agreement - Hosting Organization

The Hosting Organization agrees to complete the following assignments and adhere to established deadlines.

Yes

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 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	Minimum35 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 summary evaluations and posttests, if required by host	Minimum 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.

Hosting Organization Representative Signature(Required)

Print Name of Hosting Organization Representative(Required)

Date(Required)

This is an electronic signature(Required)

This is an electronic signature

I have read and accept all requirements and deadlines

Check here if you would like a summary of the program evaluations to be sent to the hosting organization

Please forward along this Faculty Agreement Link to your presenters. Thank you.

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.