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1. Name of Organization

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2. Provider ID Number

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3. Primary Contact

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4. Billing Contact

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5. Number of hospitals or medical centers affiliated with CME program

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6. Number of clinics/sites affiliated with CME program

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7. Is your organization part of a healthcare system?

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8. If yes, name the larger organizational healthcare system.

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9. Check the organization category that most accurately describes your organization and CME program and provide details related to the category you select.

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10. What is your geographic location(s) considered?

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11. What is the total full time equivalent (FTE) staffing dedicated to your CME program? (1.0 FTE = 40 hours/week)

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12. What are your organizations top 3 priorities for CME in the coming year?

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13. What are the top 3 challenges your organization faces in regard to CME?

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14. Which best describe your CME program support from organizational leadership?

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15. What are your best practices for showing the value of CME with your leadership?

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16. Briefly describe a CME activity that you are proud of.

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17. How can CMA better support your CME program?

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