HPH Continuing Education Preliminary Program Request Form SECTION 1: YOUR INFORMATION Your Name * Your Phone Number Your Email Address * Your Company SECTION 2: PROGRAM INFORMATION Proposed Title Proposed Date(s) Proposed Location(s) Estimated Length of the Program SECTION 3: PLANNING COMMITTEE MEMBERS There must be at least one representative for each target audience Planning Committee Members * SECTION 4: CONTINUING EDUCATION DETAILS (Check all that apply.) Target Audience Physician Physician Assistant Nurse/Nurse Practitioner Pharmacist Pharmacy Tech Social Worker Optometrist Psychologist What is the Practice-Based Issue you are trying to address with this Program What are the objectives for this Program? Type of the Activity Enduring Materials (i.e. Article, Recording, Online) Live Web-Based (i.e. Skype, Zoom) Live (i.e. Lecture, Skills Lab, Workshop) Live - RSS (Regular Scheduled Series i.e. Grand Rounds) Other (Please Specify Below) If Other, please specify Type of the Activity Who are the proposed speakers for this Program? SECTION 5: BUDGET/FUNDING FOR THE PROGRAM (Check all that apply.) Funding Registration Fees Exhibits Federal Grants State Grants Commercial Support Institutional Support Departmental Support Other (Please Specify Below) If Other, please specify Funding Sponsorship Hawaii Pacific Health (HPH) Joint Sponsorship with HPH ADDITIONAL INFORMATION: Comments