Request for Continuing Education Services

Request for Continuing Education Services
Requests for Continuing Education must be submitted in advance of your activity date.

You should submit your request 11-15 weeks before your event.

Please see the timeline below for further details.

Timeline:

Work backward from your event day.

60 days are required to process CE for Nursing, Certified Public Health (CPH), Community Health Worker, or Substance Abuse Counselor (MCBAP).

90 days are required for all other CE types not listed above.

Additionally, work cannot begin until a Statement of Work is signed. Allow two (2) weeks from the day you submit your request for services until you recieve a Statement of Work.

If MPHI Continuing Education team does not respond to your request within one (1) week of your submission, it is likely that they are unable to take requests for new work due to workloads.
Enter the first date this activity will be offered. If your request is for an enduring material activity, enter the anticipated go live date.*

MonthDayYear
Date
Activity Title*
Virtual TrainingIn-Person TrainingVirtual Conference or SymposiumIn-Person Conference or SymposiumWebinarRecorded material used for on demand learning
Main Contact Person's Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
NursingSocial Work-MichiganCommunity Health Workers (CHW)Health Educators (CHES)*Substance Abuse Counselor-Michigan (MCBAP)Physician/PA (CME I)*Teachers-Michigan (SCECH)*Lactation Consultants (IBCLC)Certified Public Health (CPH)Registered Dieticians (RD-COA)Registered Dieticians (CDR-CPE)*Certified Public Health (CPH)Healthcare Risk Manager (AHRM)*Healthcare Quality Managers (CPHQ)*Social Work-National*EMS-MichiganLaw Enforcement-Michigan (MCOLES)*Other
Anticipated Number of Attendees:*
Anticipated Number of Presenters/Trainers:*
Nurse (BSN or higher preferred)Social Worker (with valid license)Physician (MD, DO)None of the above
YesNoNot Sure Yet
YesNoNot Sure Yet
If your activity is virtual, what platform will you be using (i.e. Zoom, Teams, etc.)?
If your activity is recorded material, where will it be hosted?
I need MPHI to manage the evaluationI would like to manage my own evaluationNot sure yet
I need MPHI to manage the certificatesI would like to manage my own certificatesNot sure yet
If the funding to support this activity is managed by MPHI, what is the name of the finance contact you work with?
Upload a copy of your agenda here even if it is a draft agenda. It is used to look at the structure of your activity and calculate potential CE hours.

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If you have already completed our Quick Fill form, upload it here. If you do not have one, it will be provided when we contact you.

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Services Included in our pricing:
- Provide guidance to ensure maximum continuing education for your event.
- Collection of Relevant Financial Relationship forms (these are required for each presenter and planning committee member).
- Collection and management of educational information forms.
- Education Review to ensure education matches that expected by client.
- Completion of all forms as required by the accreditor.
- Payment of any fees required by an accreditor.
- Provide all on-site documents as needed.
- Provide the required language to be used on all marketing materials.
- Store and secure all documentation for 7 years as required by accreditors.
- Provide follow-up information to accredited provider(s) within 45 days post-event.
Event RegistrationEvent StaffingGraphic Design (i.e. logos, brochures)
Special Notes:
Should be Empty: