The RoyalCollege of Physicians of Ireland Application for Approval for CPD Accreditation

Application for Approval ofEducational Events for CPD

Applications will not be considered unless all fields below are completed and all supporting documents are included in the application package

Title of Event:this can not contain a sponsor or product name
Date(s) of Event: / Venue(s):
if the event is online, enter relevant url and access details
Duration of Education Sessions (not including registration, opening/closing speeches, breaks etc)
Relevant Medical Specialty: / Venue Location(s):
Your event should be predominantly aimed at post-training doctors, and fall under the External (Maintenance of Knowledge and Skills) category. Please enter the target medical specialty(ies) below. Do not enter roles or post-types.
Medical Organiser: / Event Administrator:
The Medical Organiser of this event assumes responsibility for ensuring the scientific validity and objectivity of the educational content. He or she must personally complete the Medical Organiser Declaration. The Medical Organiser cannot be an employee of an Industry Sponsor / The Event Administrator is the person responsible for contacting delegates, registration, and issuing of CPD attendance certificates following the event.
Name / Name
Medical Council or Professional Body and Registration Number / Position*
Organisation / Organisation
Phone/Mobile / Phone/Mobile
Email / Email
What are the objectives of the event?
What specific skills/knowledge will participants acquire during the event?
Which teaching methods will be used?
Lectures / Tutorials / Demonstrations / Practicals
Workshops / Discussion Groups / MCQs / Quizzes
Individual Performance Review
Other: (Please Specify):
Which of the Medical Council’s 8 Domains of Good Professional Practice are addressed in the educational activity? (Please tick the domain(s) applicable)
Patient safety & quality of patient care / Management (including self management) / Relating to patients / Professionalism
Communication & interpersonal skills / Collaboration & teamwork / Scholarship / Clinical skills
Is sponsorship sourced from a commercial organisation?(Tick One)
Event is not sponsored / Single Sponsor organising event  / Multiple Sponsors / Unrestricted Educational grant
Main Sponsor:
Main Sponsor Contact Name:
List all sponsors and how they are connected to the event:
What is the total value of the sponsorship?
Please describe the relationship between the sponsor(s) and the speaker(s)
Demonstration of Academic Independence
Industrysponsors must also provide the additional information listed in the Industry Sponsor section of our Guide to CPD Approval / Tick = Yes
Blank = No
The learning component of this event is unbiased / 
Display tables/material related to sponsor or sponsor’s products will not be placed in the education area (lecture theatre or room where educational content is delivered) / 
Educational programme and materials including slides, abstracts and handouts do not contain any advertising, trade or corporate message or logo / 
Meeting title and programme titles do not contain or refer to the sponsor or any product / 
The sponsorship arrangements for this event are compliant with the guidelines of the Irish Pharmaceutical Healthcare Association and/or the Code of Ethics on Interactions with Healthcare Professionals(Medical Devices) / 
Application Assessment Fee
(a) Event organised and/or hosted by a single commercial sponsor (pharmaceutical or medical device company) / €1,500
(b) Event organised and/or hosted by a professional commercial education provider / €1,500
(c) Event with multiple industry sponsors
Applications for an event supported by multiple industry sponsors may not be submitted by an industry sponsors / €500
(d) Event supported by an unrestricted educational grant
Applications for an event supported by an unrestricted educational grant may not be submitted by an industry sponsors / €500
(e) Unsponsored event with registration fee / €250
(f) Unsponsored event no registration fee
An explanatory letter from the organiser must accompany such applications / No Charge
The assessment fee is non-refundable
Payment Details
Cheque:Please staple the cheque to this form
EFT:contact us to request a reference number before submitting an electronic fund transfer
Invoice:contact us to request an invoice before you submit your application.
Purchase Order:contact us to request a reference number before submitting a purchase order
Credit Card Details
Card Number
Expiry Date
Card Type (Visa or Mastercard only)
Amount:
Cardholder:

Submit this form and supporting documents at least four weeks before you intend to circulate invitations to your event

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Professional Competence Department, RoyalCollege of Physicians of Ireland

Frederick House, 19 South Frederick Street, Dublin 2, Email: