Blue Flower

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

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)

Other Prof. 2 (Select)

Other Prof. 3 (Select)

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

# 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

CE/CME Program Type ONLY:

Programming Summary Information CE/CME Program Type Only

Method

Onsite Program Location

Distance Learning Program

Participant Profession Breakdown of All Participants

Ethnicity

Non-Hispanic

Hispanic

Attendee Age Group

Enter # of participants who indicated the following:

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