Mass General Brigham Office of Continuing Professional Development Quote Request Form

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* 1. Your name

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* 2. Your email

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* 3. Your title

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* 4. Title of activity

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* 5. Date of activity

Date / Time

Date

Time

AM/PM

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* 6. Audience: Will your activity be internal to Mass General Brigham only, or will it include external participants as well? Choose one option:

Internal

External

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* 7. Format (e.g., live course, live series, enduring activity, hybrid activity)

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* 8. Duration (e.g., 2 days, 3 hours each; monthly series with 12 one-hour sessions; enduring activity with 5 didactic lectures and quizzes)

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* 9. Credits (Here is the list we can offer credit for: Physicians, nurses, physician assistants, psychologists, social workers, dieticians, optometrists, dentists, athletic trainers, pharmacists) Options (Choose all credits you wish to offer):

Physicians

Nurses

Athletic trainers

Dentists

Dieticians

Optometrists

Pharmacists

Physician assistants

Psychologists

Social workers

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* 10. MOC II (Do you want to offer MOC for any boards? Here is the list we can offer MOC credits for.) Options (Choose all credits you wish to offer):

American Board of Anesthesiology (ABA)

American Board of Internal Medicine (ABIM)

American Board of Otolaryngology – Head and Neck Surgery (ABOHNS)

American Board of Pathology (ABPath)

American Board of Pediatrics (ABP)

American Board of Surgery (ABS)

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* 11. Marketing (Do you need any marketing support from our office?)

Yes

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* 12. Will you be seeking funding in the form of exhibits from commercial companies (e.g., pharmaceutical, device companies)

Yes

Mass General Brigham Office of Continuing Professional Development Quote Request Form

Question Title

* 1. Your name

Question Title

* 2. Your email

Question Title

* 3. Your title

Question Title

* 4. Title of activity

Question Title

* 5. Date of activity

Question Title

* 6. Audience: Will your activity be internal to Mass General Brigham only, or will it include external participants as well? Choose one option:

Question Title

* 7. Format (e.g., live course, live series, enduring activity, hybrid activity)

Question Title

* 8. Duration (e.g., 2 days, 3 hours each; monthly series with 12 one-hour sessions; enduring activity with 5 didactic lectures and quizzes)

Question Title

* 9. Credits (Here is the list we can offer credit for: Physicians, nurses, physician assistants, psychologists, social workers, dieticians, optometrists, dentists, athletic trainers, pharmacists) Options (Choose all credits you wish to offer):

Question Title

* 10. MOC II (Do you want to offer MOC for any boards? Here is the list we can offer MOC credits for.) Options (Choose all credits you wish to offer):

Question Title

* 11. Marketing (Do you need any marketing support from our office?)

Question Title

* 12. Will you be seeking funding in the form of exhibits from commercial companies (e.g., pharmaceutical, device companies)

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* 13. Will you be seeking funding in the form of commercial grants from pharmaceutical or device companies?

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* 14. Do you plan to charge tuition registration fees?

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* 15. Please add any additional information here