**CONTINUING EDUCATION (CE) REQUEST**

# CONTINUING EDUCATION (CE) REQUEST)

*PLEASE NOTE: CDC’s Continuing Education (CE) services are provided to CDC programs and CDC partners funded to develop training or for workforce development. Also, we cannot provide CE accreditation for an educational activity (e.g., webcast, web-based) that is already live and available to learners. The process of accreditation must start in the planning phase of training development.*

## CE COURSE DEVELOPER INFORMATION

Date (mm/dd/yyyy): Click or tap to enter a date.

Name:	Click or tap here to enter text.	Title:	Click or tap here to enter text.

Email:	Click or tap here to enter text.	Telephone:	Click or tap here to enter text.

## CDC INFORMATION

CDC Center or Program Office that supports this educational activity: (Do not use acronyms.)

Click or tap here to enter text.

CDC official responsible for the overall planning, educational design, content, implementation, evaluation process and scientific integrity of your activity:

Click or tap here to enter text.

Telephone:	Click or tap here to enter text.

Email:	Click or tap here to enter text.

## CDC INFORMATION

In the context of CE, a partner is defined as an organization or institution that is developing an educational activity that has received funding from a CDC grant, cooperative agreement, interagency agreement, or contract that conveys the intention to use the funding for training or workforce development. Examples of CDC partners include colleges and universities, nonprofit organizations, state health departments, and other federal agencies.

Please select your CDC funding mechanism:

☐ CDC Grant	☐ Cooperative	☐ Inter-Agency Agreement

☐ Contract	☐ Internal                      ☐ Other

Does the funding language cover the educational activity you want accredited (either explicitly or because the funding is intended for training or workforce development)?

☐	Yes	☐ No

Describe your relationship to CDC and how the funding language covers the educational activity you want accredited:

Click or tap here to enter text.

## EDUCATIONAL ACTIVITY

Title of educational activity:	Click or tap here to enter text.

Location of live activity:	Click or tap here to enter text.

Live	☐ Not applicable	☐ Series (varying content under topic)

	☐ Course 	☐ Recurring Program (same content repeated)

	☐ Live Internet	☐ Conference****(concurrent breakout sessions)

	☐ Manuscript Review

Enduring Materials:	☐ Not applicable	☐ Journal Activity

	☐ Enduring Material	☐ Other

	☐ Internet Enduring

Please describe your educational activity:

Click or tap here to enter text.		****

**Educational activity start date (mm/dd/yyyy):**Click or tap to enter a date.

**Type of credit desired:***(You may choose all that apply.)*
If the type(s) of credit desired is not listed, please include this accreditation type in the “Comments” field with a brief justification. We will assess the feasibility of adding this new accreditation type in the future and/or suggest alternatives for accreditation. 

☐ CME	☐ AAPA CME	☐ CNE	

☐ CPE	☐ CEU	☐ CPH

☐ AAVSB/RACE	☐ CHES/MCHES	☐ ALL

Comments:

Click or tap here to enter text.

Please sign and return this completed CE request in MS WORD format, to cerequests@cdc.gov. If you have any questions, please contact cerequests@cdc.gov. 

Click or tap here to enter text.	Click or tap to enter a date.

**Signature (may be typed)	Date**

   Center for State, Tribal, Local, and Territorial Public Health Infrastructure and Workforce

   Center for State, Tribal, Local, and Territorial Public Health Infrastructure and Workforce	July 2023

# image1.jpg

# image2.jpg

# image3.jpg

# image4.png