Continuing Professional Development
Application for External CPD Activity Approval
Please save this form and email it with the activity's finalised programme and the evaluation form to .
Title
Start date / End date
Venue
Address
Attendance fee(s) / £ / Expected number of attendees
Feedback methodology / ☐Evaluation form (attached) / ☐ Online Survey
Link if online survey
Assessment method / ☐ Yes ☐ No / If yes, please describe
ORGANISER DETAILS
Activity organiser
Professional address
Contact person
Email*
Phone*
* Please note that the email address and phone number provided here will be displayed publicly on the CPD Diary and RCPCH website, and available to delegates wishing to contact you about the course/event. We would therefore discourage personal information being provided for this purpose.
ORGANISATION & FEE DECLARATION☐ By crossing this box the organiser:
1. declares that either the programme and the selection of speakers or educationalcontent of any part of the meeting is not biased by a sponsor or other commercialinterest, or, where this is the case, this is clearly identified in the accompanyingpapers;
2. agrees for the activity and organiser details to be uploaded onto the online CPDdiary system (accessible to RCPCH CPD scheme participants);
3. confirms that clinical content follows all appropriate patient consent guidance,confidentiality policies, data governance and GMC Good Medical Practice principles;
4. declares that `Declaration of Interest' forms will be completed by speakers/thoseinvolved in developing the education content and that this information will beavailable to participants prior to or at the start of the relevant session.
5. confirms that the public sector equality duty requirements, as laid out in section 149(1) of the Equality Act 2010, have been considered in relation to e.g. venue and course content accessibility, speaker selection
Sponsors
☐ No sponsors
CPD approval sought from other organisation(s): / ☐ Yes / ☐ No
If yes, please name organisation and describe outcome
Type of organisation /
☐ Commercial/ for-profit/ pharmaceutical company - £375.00
☐ Non-commercial organisation with income stream - £36.00
☐Non-commercial organisation with no income stream – no charge
Please note that a late fee is applicable for commercial submissions made 21 days or less prior to the date of the event and non-commercial submissions made 10 days or less prior to the date of the event. For further information please visit:
Payment
☐Card / ☐Cheque / ☐Invoice
Card:
Card type
Please specify(Visa Electron/Debit/Credit, MasterCard, Maestro, etc.)
Card number
(16 digit number that appears on the front of the card)
Name on card(Cardholder)
Expiry date
☐I authorise you to debit my cardwith the amount of: / £
Cheque:
Please send a cheque on a UK bank payable to 'RCPCH'to RCPCH, 5-11 Theobalds Road, London WC1X 8SHafter you receive an email from us confirming CPD approval - we will let you knowwhat reference number to quote. / £
Invoice:
Address the invoice to:
PO number (optional)
☐ By crossing this box I hereby sign the form electronically
Name:
Date:
CPD team / Regional Advisor ONLY
Category of Approval: / Clinical☐Professional☐
Comments (optional)
Name:
Date
☐ By crossing this box I hereby confirm approval of this activity.