The Rollins School of Public Health of Emory University

CONTINUING EDUCATION FOR CHES/MCHES

PROGRAMEVENT PROPOSAL FORM

  1. Title of Activity or Event:
  1. Is this Activity an enduring material piece (such as a CD-Rom, Videotape, Audiotape, Printed Material, Webcast, etc.)?  YES  NO

If YES, you must complete a pilot test review of the product and submit a completed Pilot Test Summary Form.

  1. Date of Live Event or Range of Dates for Series or for Enduring Event:
  1. Primary Sponsor:
  1. Co-sponsors or Partners (The Rollins School of Public Health of Emory University must be identified here, on promotional and on-site materials as a sponsor, co-sponsor or partner):
  1. Number of Category I continuing education contact hours (CECH's) to be offered:
  • Number of entry-level CECH: ______
  • Number of advance-level CECH: ______

Calculation of Hours: CECH will be calculated by rounding up to the nearest 1/2 hour. Examples: 1 hour and 45 minutes = 2 hours; 2 hours and 15 minutes = 2 1/2 hours; 2 hours and 10 minutes = 2 hours; 2 hours and 35 minutes = 2 1/2 hours. For multiple event sessions, add all minutes before rounding.

  1. Intended audience:
  1. Expected number of participants: Total participants:CHES/MCHES participants:
  1. Meets criteria for continuing education for health educators defined as: Educational experiences “that assist in the development or enhancement of knowledge and skills directly related to the areas of responsibility and the individual’s professional occupation." From NCHEC, Inc. (See list of competencies):  YES  NO
  1. Name of active CHES/MCHES involved on the planning committee from the Rollins School of Public Health (multi-event provider organization):

Name of CHES/MCHES involved on the planning committee from co-sponsoring agency:

  1. Method of assessing educational needs of intended audience (i.e., survey, previous conference evaluations, etc.):
  1. Conference faculty (presenters and their credentials) -- please include their biographical sketch here or attach their bio, resume or CV:
  1. Program presentation methods (lecture, panel discussion, small group discussion, video, interactive computer-based activities, etc.):
  1. Method of evaluating programs (please attach proposed evaluation form):
  1. Method of attendance documentation and verification (please attach proposed sign-in sheet, roster, or registration/attendance/completion form, if an enduring material piece):
  1. Using the required RSPH certificate template which will be sent to you if activity is approved, do you agree to provide each participant requesting CECH credit a certificate at the end of the event (or at least within 4 weeks after the event) and to provide RSPH with a copy of all certificates?

 YES NO

  1. Please submit the activity agenda and for each session, please submit the following: title, objectives and the CHES responsibility/competency addressed, and number of contact hours to be awarded. If requesting advance-level credits, please indicate the advance-level competencies addressed.
  1. Contact person (s) for the sponsoring organization:

Include the following with this application form:

Program Agenda (if live event) or Content Outline (if Enduring Material) with session/section titles, learning objectives, and CHES entry-level and advance-level competencies identified

Faculty Bios/CV

Evaluation Form

Test/Quiz/Assessment Form & Answer Sheet (if Enduring Material)

Pilot Test Summary Form (if Enduring Material)

Method of Attendance Documentation/Verification

Submit to:

Laura M. Lloyd, MPH, MCHES, Rollins School of Public Health

1518 Clifton Rd., Room 240, Atlanta, GA 30322

Phone: (404) 727-3035 FAX: (404) 727-1835; Email:

Please note: The review process may take up to two weeks.

Updated: 2014