Local Chapter Resources

Continuing Education Activity Planning Form

Please note: forms must be submitted 60 days prior to event.

Activity Information

Title of Activity:

Proposed Date(s) of Activity:

Activity Format:

Location:

Activity Overview

1. Purpose. Please provide the overall purpose of and target audience for this educational activity.

2. Objectives. Briefly list 3-5 draft objectives for this educational activity.

Activity Contact Person

Contact Name:

Phone:

Email:

Planning Committee

Please list names and credentials of the individuals involved in the planning of this activity

Type of Local Council Chapter Education Activity Accreditation Requested

CAP (ACCME)
CNSW (ASWB) (Click here for the CNSW (ASWB) Planning Form)
CNNT (NYSNA)
CRN (ADA- CDR)

Are you working with an NKF office on this program? Yes     No

If so, please list office name and primary contact name: