GEC PROGRAM Add

GEC PROGRAM ADD

Official Name:
Program Series add new series
Recurring Program add new
Program Number
Contact Person


Contact Hours:	Fee:
Actual Contact Hours
Total Number of Days of Pgm
Social Work CE Credit Hours	Social Work CE Fee:	$
Nursing CE Credit Hours	Nursing CE Fee:	$
MD/DO CME Credit Hours	MD/DO CE Fee	$
Allied Health CE Credit Hours	Allied Health CE Fee	$
Nursing Asst Credit Hours	Nursing Asst CE Fee	$
Pharmacology Credit Hours	Pharmacology CE Fee	$
Credit Hours	Other CE Fee	$
Credit Hours	Other CE Fee	$
Credit Hours	Other CE Fee	$
	General Program Fee	$
	Student Fee	$
	Senior Fee	$
	Meals	$
	Housing	$


Program Delivery Information (check all that apply)
	Live/In-person	CD-ROM
	Web-based/online	Audio cassette
	Video	Other

Program Type (check all that apply)
	Continuing Education	Curriculum Development
	Fellowship/Residency	Clinical Training
	Faculty Training/Faculty Development	Interdisciplinary Team
	Faculty Retraining

Location of Clinical Training (check all that apply)		Underserved Area
	Ambulatory Care Center
	Assisted Living
	Chronic and Acute Disease Hospital
	Home Care
	Hospice
	Nursing Homes
	Palliative Care
	Senior Centers
	Senior Housing
	Telehealth
	Other

Program Enrollment Goals		Number Expected
Under-represented minorities
Trainees for primary care career
Clinical training in underserved areas

Sponsors/Partnerships/Leveraging
Name of Organization		Role





Faculty / Speakers		Number of hours





Program Objectives

What Special Topics Apply to This Program's Content? Check ALL that apply
		Adolescent Health		HIV/AIDS
		Alternative Medicine		Interdisciplinary Training
		Ambulatory Care		Long Term Care
		American Indian		Managed Care
		Behavioral Health		Maternal Child Health
		Bioterrorism		Medical Economics
		Border Health Activities		Mental Health
		Community-Based Continuity of Care		Minority Health Issues
		Cultural Competence		Nutrition
		Distance Learning		Oral Health
		Domestic Violence		Patient Safety/Medical Errors
		Evidence Based Medicine		Quality Improvement in Health Profession
		Faith Based		Research
		Faculty Development		Rural Health
		Health Promotion/Disease Prevention		Substance Abuse/Prevention
		Home Health		Telemedicine/Telehealth
		Homeless		Urban Health
		Informatics		Womens Health
		Genetics		Other
		Geriatrics

	Clinic Sites in Underserved Areas		Diseases
		Community Health Centers		Asthma
		Governor Designated Area		Diabetes
		Health Departments		Cancer
		HPSA - Health Professions Shortage Area		Obesity
		Migrant Health Centers		Tuberculosis
		Rural Health Clinics		STD
		Other Clinical Site		Other Diseases

	Minority Recruitment/Retention
		Hispanic
		African American
		Am Ind/Alaskan Native
		Native Hawaiian


What Are the Target Audiences for This Program? Check ALL that apply
		Allopathic Medicine Osteopathic Medicine
		Chiropractic
		Dentistry
		Nursing
		Pharmacy
		PhysicianAssistant
		Podiatry
		Clinical Laboratory Sciences
		Dental Hygiene/Asst/Tech
		EMT
		Health Information
		Home health Aide/ Medical Assistant
		Nutrition
		Rehabilitation Therapies
		Rehabilitation Specialties
		Technician
		Other Allied Health, Specify:
		Gerontology
		Clinical Psych/Counseling
		Other Counseling
		Health Administration
		Nursing Home Administrator
		Health Education
		Law (Attorney, Paralegal)
		Law Enforcement
		Protective Services
		Pastoral Care
		Public Health
		Dental Public Health
		Social Behavioral Sciences
		Social Work