Name of the Society/Institution *

Address *

City *

Postal code *

Country *

Phone (incl. country code) *

Fax (incl. country code) *

Website

Last Name *

First Name *

If different from above:

Address

City

Postal code

Country

E-mail address *

Direct phone (incl. country code) *

Direct fax (incl. country code) *

Last Name *

First Name *

If different from above:

Address

City

Postal code

Country

E-mail address *

Direct phone (incl. country code) *

Direct fax (incl. country code) *

Title of the web-based course *

Please upload the full programme of your activity

Please upload the full programme of the activity here

Accreditation will concern:

Accreditation will concern Entire content Only one part of the content

If only part of the content, please specify which part of the content it will concern

If only part of the content, please specify which part of the content it will concern

URL of web-based course
(If URL is not final yet, please provide with a temporary URL of web-based course, which we will use only for reviewing purposes)

URL of web-based course

Login

Password

Is it:

It is A temporary URL The final URL

Fee For participants (Euro): *

Will technical support be provided to participants?

Will technical support be provided to participants? Yes No

If yes, please specify the kind of technical support provided

If yes, please specify the kind of technical support provided

Please provide a description of the educational aims and method

Please provide a description of the educational aims and method

Target audience

Taget audience

Duration of the entire course

Duration of the entire course *

Is the content divided into several sections/sessions/modules? *

Is the content divided into several sections/sessions/modules? * Yes No

If yes, please specify for which section/sessions/Modules you wish to obtain accreditation

If yes, please specify for which section/sessions/modules you wish to obtain accreditation

Course Faculty: Please attach a list of all faculty members
Please note that each member of the faculty must complete and sign the "Disclosure Form"

Course Faculty: Please attach a list of all faculty members *

Please note that EBAP requires that providers of accredited CME programmes inform their audience about the disclosed/indicated conflicts of interest
This should be done by placing relevant information on the home page of the web-based course and at the beginning of each session/module.
EBAP recommends using the standard "EBAP standard text on disclosure" which is available on the "document library" page of EBAP website.

Will you be using the standard EBAP text on disclosure? *

Will you be using the standard EBAP text on disclosure? * Yes No

If no, please type your text in

Will you use any commercial support for the accredited web-based course? *

Will you use any commercial support for the accredited web-based course? * Yes No

If yes, please indicate the type and origin of this support
Please indicate the name of company(ies) and type of service(s)

If yes, please indicate the type and origin of this support

Will there be any advertising / promotion included to the web-based course? *

Will there be any advertising / promotion included to the web-based course? * Yes No

If yes, please indicate which kind of advertising

If yes, please indicate which kind of advertising Advertising Logo Links to sponsor's website Other

If other, please specify

Please provide the name(s) of the advertising company(ies)

Please provide the name(s) of the advertising company(ies)

Will the programme be evaluated by participants? *

Will the programme be evaluated by participants? * Yes No

If yes, how will the programme be evaluated by participants?

If yes, how will the programme be evaluated by participants? EBAP standard evaluation forms Other type of evaluation forms Other

If other, please specify

If you plan to use a different evaluation form than EBAP's standard evaluation form, please upload your form

If you plan to use a different evaluation form than EBAP's standard evaluation form, please upload your form

Will participants' knowledge be evaluated? *

Will participants' knowledge be evaluated? * Yes No

If yes, how?

If yes, how will the knowledge of participants be evaluated? Multiple choice questionnaire (MCQ) Other

If other, please specify

Please upload the MCQ (if already available)

Please upload the MCQ (if already available)

How will CME certificates be distributed to participants? *

How will CME certificates be distributed to participants? * Paper Online Other

If other, please specify

If you wish to receive a notification e-mail with a copy of your web-based event accreditation request, please indicate to which e-mail address it should be sent to here below

Notification e-mail address