Free 50690.pdf - Indiana

INDIANA BOARD OF PODIATRIC MEDICINE
APPLICATION FOR APPROVAL OF CONTINUING EDUCATION PROGRAM FOR PODIATRIC MEDICINE
State Form 50690 (11-01) Approved by State Board of Accounts, 2001

BUREAU ADDRESS INDIANA BOARD OF PODIATRIC MEDICINE 402 WEST WASHINGTON STREET, ROOM W041 INDIANAPOLIS, IN 46204 INFORMATION AND INSTRUCTIONS BEFORE COMPLETING AND SUBMITTING YOUR APPLICATION TO OUR OFFICE, PLEASE READ ALL INSTRUCTIONS CAREFULLY. IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT THE HEALTH PROFESSIONS BUREAU AT (317) 234-2064.

STATUTE AND RULES A COPY OF THE PODIATRIC MEDICINE PRACTICE ACT AND ADMINISTRATIVE RULES ARE AVAILABLE UPON REQUEST.

APPLICATIONS MAY BE SUBMITTED UP TO 30 DAYS AFTER PROGRAM DATE Programs for continuing podiatric medical education may be approved by the board provided the sponsoring organization, or the licensee who attended , has submitted the application no later than thirty (30) days after presentation of the program.

APPROVAL CERTIFICATES Upon approval by the Board, a certificate will be issued with the number of hours the program has been approved for.

THE FAIR INFORMATION PRACTICE ACT In compliance with IC 4-1-6, this agency is notifying you that you must provide the requested information or your application will not be processed. You have the right to challenge, correct, or explain information maintained by this agency. The information you provide will become public record.

1

INFORMATION REQUIRED TO BE SUBMITTED WITH APPLICATION 1.) PROGRAM BROCHURE OR OTHER INFORMATION: A copy of the program brochure or a draft copy of the information to be provided in the brochure must be attached to each application. 2.) TIME INTERVALS: Specific time intervals for each activity must be provided, if not stated in the brochure. 3.) TIME ALLOWANCES: Time allowances for any scheduled non-instructional activities such as coffee breaks must also be included.

APPROVAL OF CONTINUING EDUCATION PROGRAMS 845 IAC 1-5-3 Approval of continuing education programs Authority: IC 25-29-2-11 Affected: IC 25-29-6-4 (a) The following criteria shall be used in evaluation of approval of continuing podiatric medical education: (1) The continuing education program shall have a statement of objectives, which the program should achieve for its participants. (2) The sponsor of continuing education programs shall provide adequate administration, including a responsible person to coordinate and administer the program, and shall provide for the maintenance of proper records. (3) Sponsors of continuing education programs shall provide adequate funding for the education programs undertaken. (4) The curriculum of a continuing education program shall be thougtfully planned and designed to explore in considerable depth, one (1) subject or a closely related group of subjects. (5) The continuing education program shall have qualified faculty members who have demonstrated competence in the subject areas. (6) The continuing education program shall be held in adequate facilities that allow for an effective program. (7) Continuing education programs shall employ a variety of educational methods and teaching aids that enhance the learning opportunities. (8) Appropriate methods of evaluation shall be devised and used to measure the program's effectiveness. (9) The sponsor of the continuing education program shall provide to the participants a meaningful record of attendance stating the continuing education units involved. (b) Programs for continuing podiatric medical education may be approved by the board provided the sponsoring organization, or the licensee who attended, has submitted the proper form no later than thirty (30) days after presentation of the program and submits the fee for evaluation as provided in 845 IAC 1-6-8. (c) The sponsor of the program is responsible for monitoring attendance in such manner that verification of attendance throughout the entire lecture can be reliably assured.

2

APPLICATION FOR APPROVAL OF CONTINUING EDUCATION PROGRAM FOR PODIATRIC MEDICINE
State Form 50690 (11-01) Approved by State Board of Accounts, 2001

INDIANA BOARD OF PODIATRIC MEDICINE 402 WEST WASHINGTON ST., ROOM W041 INDIANAPOLIS, IN 46204 (317) 234-2064

DO NOT WRITE IN THIS BOX - FOR OFFICE USE ONLY
Hours granted

Certificate issuance date

SPONSORING ORGANIZATION
Name of sponsor

Address (number and street, city, state, ZIP code)

Telephone number

Website URL

PROGRAM COORDINATOR
Name of coordinator

Address (number and street, city, state, ZIP code)

Telephone number

Email address

TITLE OF PROGRAM TO BE OFFERED
Program title

Date(s) of program

Location of program (city and state)

Number of instructional clock hours involved in the program

TYPE OF PROGRAM CONFERENCE INSTITUTE SEMINAR WORKSHOP SHORT COURSE SPECIAL TRAINING PROGRAM OBJECTIVES List the objectives for the continuing education program.

3

ADMINISTRATION
1. Who planned the overall program? 2. Are clinical procedures involved in the program? If so, how?

Yes

No

3. When will the program brochure be mailed?

4. Who will maintain adequate records of program participants and certify to their accuracy?

BUDGET
1. List the proposed budget for each applicable item listed below for this program:

A.) Faculty honoraria and expenses: B.) Facilities: C.) Staff expenses: D.) Clerical assistance: E.) Publicity: F.) Printing: G.) Preparation of materials: H.) Other administrative costs: TOTAL COST:
2. What is the proposed tuition or registration fee for the program?

$ $ $ $ $ $ $ $ $

Practitioners: Students:

Residents: Others:

3. What is the refund policy for those canceling registration in ample time for that space to be filled by another person?

4. What is the anticipated enrollment?

CURRICULUM List the curriculum by subject areas, the clock hours planned, the faculty members, and the proposed method of presentation for each subject area. If more space is needed please attach these explanations on a separate sheet. SUBJECT CREDIT HRS FACULTY METHOD OF PRESENTATION

FACULTY 1.) PODIATRISTS College Faculty: ___________________ 2.) OTHER PRACTITIONERS Medical Doctors: ___________________ Doctors of Osteopathy: ___________________ Private Practice: ___________________

3.) OTHERS: (Please explain) __________________________________________________________________________________________________ TOTAL # OF FACULTY:____________________ FACILITIES
1.) At what type of facility will the program be conducted?

4

FACILITIES (Continued)
2. List any clinics or hospitals involved for part of the training program.

EDUCATIONAL METHODOLOGY
1.) Check the educational methods being employed in the program:

Lectures Live Clinic Bedside Rounds Laboratory Work
2.) What teaching aids will be used? (Check applicable boxes)

Patients Receiving Care Practical Experience Group Discussion Question / Answer Periods

VIDEO CHARTS SLIDES OTHER:

BLACKBOARD TELEVISION OVERHEAD PROJECTORS

3.) If the group is to be divided for some of the program, list the approximate size and the type of method to be employed:

EVALUATION
1.) What type of evaluation will be conducted to measure the program's effectiveness?

2.) Will evaluation results be made available to faculty members?

3.) Will an evaluation be made of the individual participant?

4.) How will the evaluation be used to improve future program offerings?

CERTIFICATE OF ATTENDANCE

According to 844 IAC 1-5-3(1)(9): The sponsor of the continuing education program shall provide to the participants a meaningful record of attendance stating the continuing education units involved.
COUNCIL ON PODIATRIC MEDICAL EDUCATION (CPME)
1.) Has the program been submitted to the CPME for approval? If so, was the program approved?

Yes

No

Yes

No

2.) If your program was not approved by CPME, please state the reason why.

5