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CE/CME Program Type ONLY:
Programming Summary Information CE/CME Program Type Only
Use Non-CE for all other Program Summary Types
Program Information
Event Title:
Number of Topics presented (Titles will be entered on following pages)
Program Partners:
Program Start Date
Program End Date
Method
Live
Web-Based
Video Broadcast
Audio Conference
Other Mode
Onsite Program Location
Rural
Urban
City:
Distance Learning Program
# of Rural Sites
# of Urban Sites
Participation Summary
Total # Participants:
Program Participants (Must equal total above)
Total # Health Professional Participants
(CE applies to license or cert. req.)
Total # Students in Healthcare Training
Total # Other Attendees
Other Attendees List:
Participant Profession Breakdown of All Participants
Physician (Allopathic)
Dentist
Hygienist
Nurse (RN)
NurseLPN
Adv. Practice Nurse (NP)
Pub. Health Nurse or Specialist
Physician Assistant
Phys. Therapist (Allied)
Social Worker
Psychologist
Health Professions Student
#
Other Prof. 1 (Select)
Audiologist
Community Health Worker
Dietician/Nutritionist
EMT/Paramedic/Fire Rescue
Epidemiologist
Health Administrator
Health Education Specialist
Health Information Systems/Data
Home Health Aide
Marriage and Family TherapistMarriage and Family Therapist
Medical Assistant
Nursing Assistant
Nurse Midwife
Occupational Therapist
Optometrist
Pharmacist
Physician, Osteopathic Medicine
Professional Counselor
Speech Therapist
Unknown
#
Other Prof. 2 (Select)
Audiologist
Community Health Worker
Dietician/Nutritionist
EMT/Paramedic/Fire Rescue
Epidemiologist
Health Administrator
Health Education Specialist
Health Information Systems/Data
Home Health Aide
Marriage and Family TherapistMarriage and Family Therapist
Medical Assistant
Nursing Assistant
Nurse Midwife
Occupational Therapist
Optometrist
Pharmacist
Physician, Osteopathic Medicine
Professional Counselor
Speech Therapist
Unknown
#
Other Prof. 3 (Select)
Audiologist
Community Health Worker
Dietician/Nutritionist
EMT/Paramedic/Fire Rescue
Epidemiologist
Health Administrator
Health Education Specialist
Health Information Systems/Data
Home Health Aide
Marriage and Family TherapistMarriage and Family Therapist
Medical Assistant
Nursing Assistant
Nurse Midwife
Occupational Therapist
Optometrist
Pharmacist
Physician, Osteopathic Medicine
Professional Counselor
Speech Therapist
Unknown
#
Remaining Profs. List (Enter discipline and number of each; i.e. CNAs-10, Pharmacists-2, etc.)
Organizations of All Participants
Federally designated CHC or FQHC
Other Designated: Migrant Health Center (MHC), National Health Service Corp (NHSC), Rural Health Clinic (Federally Designated), Health Department, Federally Designated HPSA, Governor Designated Ambulatory Practice Site, Health Care for Homeless (Federally Designated), Indian Health Service (IHS) / Tribal Health Site, Public Housing Primary Care Grantees
Other Medically Underserved Sites such as: School health services and health clinics, Emergency care facilities, State owned facilities for indigent care, teaching hospitals, and other teaching facilities with a Medicaid/Medicare patient population of 50% or more of the total patient population, Sites with un-insured patient population greater than the national average, Ambulatory practice sites with a Medicaid/Medicare patient population of 50% or more of the total patient population including public, non-profit, faith-based, charity, and other types of clinics
Non-Underserved Community
Rural Setting (non MSA)
Other/Unknown
Participant Statistics
Ethnicity
Minority
Non-Minority
Non-Hispanic
Hispanic
# African American
# Asian
# Caucasian
# Am. Indian
# Pac. Island
# Disadvantaged Caucasian
# African American
# Asian
# Caucasian
# Am. Indian
# Pac. Island
Attendee Parish(es) (if known)
Attendee Age Group
Under 20
20-29
30-39
40-49
50-59
60-69
70 or Older
Male
Female
HPSA
NonHPSA
Rural
Urban
Enter # of participants who indicated the following:
# Increased knowledge or Skill
# Intent to implement
Credit Hours Summary
CE Credit Offered
Yes
No
# CE Hours Offered for Event
Attendees earning CE for License or Cert. req.
Total CE Hours Generated for Event
CE Credit Type:
Physician
Nurse
Nurse Practitioner
Physician Assistant
Pharmacist
Dentist
Hygienist
Mental Health
Physical Therapist
Allied Health
Other #1
Other #2
Other #3
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