Name of Publisher *

Address *

City *

Postal code *

Country *

Phone
(incl. country code)

Fax
(incl. country code)

Website

Please provide a list the Publisher's main journals:

Please provide a list the Publisher's main journals *

Quality recognition: please indicate whether any of the publisher's journals or articles were recognised or accredited by medical or scientific accreditation boards or used in medical teaching institutions

Quality recognition: please indicate whether any of the publisher's journals or articles were recognised or accredited by medical or scientific accreditation boards or used in medical teaching institutions

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 CME article *

Article *
(please upload file)

Title of the journal in which the article will be published *

Estimated time needed for a comprehensive reading of the article*
(please indicate time in minutes)

Estimated time needed for a comprehensive reading of the article *

Number of words the article contains*
(approximately)

Number of words the article contains  *

Target audience *

Educational aims and methods (please describe)

Educational aims and methods

How will the CME article be accessed?

How will the CME article be accessed?

 Paper

 Online

 Other

If other, please specify:

Last Name *

First Name *

Address

Postal code

City

Country

E-mail address

Last Name

First Name

Address

Postal code

City

Country

E-mail address

Please note that EBAP requires that providers of accredited CME programmes inform their audience about the disclosed/indicated conflicts of interest by placing relevant information at the end of the CME article.
(EBAP recommends using the 'EBAP standard text on disclosure' which can be downloaded from the 'document library' page)

Will you use EBAP's standard text on disclosure?

Will you use EBAP's standard text on disclosure?

 Yes

 No

If no, please type your text in:

Will the article be evaluated by readers?

Will the article be evaluated by readers?

 Yes

 No

If yes, how?

If yes, how will the article be evaluated by readers?

 EBAP standard evaluation forms

 Other type of evaluation form

 Other

If other, please specify

If you do NOT plan on using the EBAP standard evaluation form, please upload your evaluation form

Evaluation form upload

Will reader's knowledge be evaluated?

Will reader's knowledge be evaluated?

 Yes

 No

If yes, please specify how

If yes, please specify how

 Multiple Choice Questionnaire (MCQ)

 Other

If other, please specify:

If you intend to provide a MCQ, please upload the questionnaire

MCQ file

How will CME certificates be distributed to readers?

How will CME certificates be distributed to readers?

 Paper

 Online

 Other

If other, please specify:

Will you use any commercial support for the accredited article?

Will you use any commercial support for the accredited article?

 Yes

 No

If yes, please indicate:

The type of this commercial support

The type of this commercial support

The origin of this commercial support
(please indicate the name of the company and type of service)

The origin of this commercial support

Will there be any advertising / promotion included to the CME article?

Will there be any advertising / promotion included to the CME article?

 Yes

 No

If yes, which kind of advertising / promotion?

If yes, which kind of advertising / promotion?

 Advertising

 Logo

 Links to sponsors websites

 Other

If other, please specify

The origin of this advertising
(please indicate the name of the company(ies) and type of service(s))

Names of advertising companies

If you wish to receive a notification e-mail with a copy of your CME Article Accreditation Form, please indicate to which e-mail address it should be sent to here below

Notification e-mail address