(For HKCR Fellows & non-FHKCR Specialist Only)

HONG KONGCOLLEGE OF RADIOLOGISTS

APPLICATION FOR CME/CPD CREDIT
Grant Assessing, Local/Overseas Hands-on Clinical Attachment & Development of New Technologies or Services
FOR OFFICIAL USE / Ref. No.: / Signature:
Date Received : / CME/CPD Points Awarded / Category

Chairman of

CME/CPD Subcommittee

Notes :-

(a) / This form is applicable to the following activities: assessing grant applications; local/overseas hands-on clinical attachment programme; development of new technologies or services
(b) / Application ofAssessing Grant Application should be submitted not later than one month after the end of cycle year.
(c) / Applications ofLocal/Overseas Hands-on Clinical Attachment ProgrammeDevelopment of New Technologies or Servicesshould be submitted together with proper documentation 2 weeks prior to the dates of the activities / commencement of the project.
(d) / Please use BLOCK LETTERS and TICK where appropriate. Please complete Section A for applying the Active CME/CPD point(s) forGrant Assessing; Section B for Local/Overseas Hands-on Clinical Attachment Programme; or Section C for Development of New Technologies or Services.
(e) / Application will be proceeded upon completed application form and sufficient documentation have been submitted to the College by email at or by fax at (852) 2554 0739 or by mail.
Processing this application may take at least 1 month, please apply early.

Part I) Information of Applicant

Name of Applicant: / Contact Tel No.:
Name of Department & Hospital / Institution: / Contact Fax No.:
Contact Address: / Contact Email:

Part II) Details of Activity

Section A: Active CME/CPD point(s) applied for Grant Assessing:

(1) / Name of Grant :
(2) / Date of Assessment:
(3) / Letter of invitation for assessing grant applications provided:
Yes
Total no. of Active CME/CPD point(s) to be applied:(Refer to CME/CPD Guidelines Section 4.5.11 for details.) / (Cat. A)

Section B: Active CME/CPD point(s) applied for Local/Overseas Hands-on Clinical AttachmentProgramme:

(1) / Name of Hands-on Clinical Attachment Programme:
(2) / Name of Accredited Training Unit:
(3) / Attachment Period :
(4) / Report with a summary of no less than 250 words provided:
Yes / To be submitted to HKCR in due course
(5) / Certificate of Attendance provided:
Yes / To be submitted to HKCR in due course
Total no. of Active CME/CPD point(s) to be applied :
(Refer to CME/CPD Guidelines Section 4.5.12 for details.) / (Cat. A / Cat. B)

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Section C: Active CME/CPD Point(s) applied for Development of New Technologies or Services:

(1) / Name of Project:
(2) / Project Conducting Period:
(3) / Status of applicant :
First 3 investigator(s) / Other investigator(s)
(4) / Project Action Plan of no less than 250 words provided:
Yes
Total no. of Active CME/CPD point(s) to be applied :
(Refer to CME/CPD Guidelines Section 4.5.14 for details.) / (Cat. A / Cat. B)

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Total no. of Active CME/CPD point(s) to be applied:
Section A: Grant Assessing / Cat. A
Section B: Local/Overseas Hands-on
Clinical Attachment Programme / Cat. A / Cat. B
Section C: Development of New Technologies or Services / Cat. A / Cat. B
Total: / Cat. A / Cat. B
Signature of Applicant / Date

Page 1Revised in July 2017