CPD accreditation application

"*" indicates required fields

Step 1 of 9 – Activity title and applicant details

11%

Fees and Terms*

I understand and will comply with the fees and terms for accreditation of CPD activities as outlined in the CPD accreditation guidance document.
You must answer ‘Yes’ to complete this form.

Yes

Title of Activity*

Name of group / organisation applying*

Name of contact person for this application*

First Last

Contact Email*

Contact telephone*

Proposed date of event*

Activity: {Title of Activity:3}

Does your group / organisation have an overdue evaluation report?*

Yes – you are not eligible to apply for accreditation

Is this an AdPha activity (e.g. Branch CE, AdPha Seminar)

Yes

Supporting information

If this is your organisation’s first CPD accreditation application with AdPha you will need to provide following supporting information with your application.
1. Organisation’s mission statement and raison d’être.
2. Organisation’s ABN and if the organisation is a registered training organisation.
3. Details on the organisation’s membership and affiliations.
4. Organisation’s conflict of interest policy and privacy policy.
5. Organisations procedure for handling grievances / complaints.
6. If required, the organisation’s anti-discrimination policy.
This information must be supplied to AdPha within 2 business days of your accreditation application being received.

Activity: {Title of Activity:3}

The following information will assist AdPha to determine whether an activity meets the standard to be accredited
(i.e. is suitable for consideration for an individual pharmacist’s CPD plan in accord with the goals of the PBA)

Customer needs (market) analysis*

What is the purpose of the activity?

Has the program been run before?*

Yes

How did you incorporate feedback from previous events into the development of this activity?

How was the need for the program assessed?*

Who is the target audience?*

How will the program meet adult learning principles?*

Name the pharmacist(s) involved in the development of this program and describe their role(s):*

Were additional non-pharmacist subject matter experts involved in the development of this program?*

Yes

Name the non-pharmacist subject matter expert(s) involved in the development of this program and describe their role(s):

Activity: {Title of Activity:3}

What is the nature of the activity?

Single activity (e.g. face-to-face lecture)

Repeated activity (e.g. online or seminars)

Duration of Accreditation sought (in years)

Please enter a number from 0 to 3.

Maximum of three years

Learning objectives for program as a whole*

Program format*

Total duration per CPD activity group.

Group 1

Information accessed without assessment (hours)

Group 2

Knowledge or skills improved with assessment (hours)

Activity: {Title of Activity:3}

Competency standards addressed by the program

Please consult the National Competency Standards Framework for Pharmacists in Australia, 2016 to assist you in choosing the standards that your program (as a whole) addresses below. Check the boxes next to relevant pharmacist competency standards.

Domain 1: Professional and ethical practice

Standard 1.1 Uphold professionalism in practice

Standard 1.2 Observe and promote ethical standards

Standard 1.3 Practice within applicable legal framework

Standard 1.4 Maintain and extend professional competence

Standard 1.5 Apply expertise in professional practice

Standard 1.6 Contribute to continuous improvement in quality and safety

Domain 2: Communication and collaboration

Standard 2.1 Collaborate and work in partnership for the delivery of patient-centred, culturally responsive care

Standard 2.2 Collaborate with professional colleagues

Standard 2.3 Communicate effectively

Standard 2.4 Apply interpersonal communication skills to address problems

Domain 3: Medicines management and patient care

Standard 3.1 Develop a patient-centred, culturally responsive approach to medication management

Standard 3.2 Implement the medication management strategy or plan

Standard 3.3 Monitor and evaluate medication management

Standard 3.4 Compound medicines

Standard 3.5 Support quality use of medicines

Standard 3.6 Promote health and well-being

Domain 4: Leadership and management

Standard 4.1 Show leadership of self

Standard 4.2 Manage professional contribution

Standard 4.3 Show leadership in practice

Standard 4.4 Participate in organisational planning and review

Standard 4.5 Plan and manage physical and financial resources

Standard 4.6 Plan, manage and build human resources capability

Standard 4.7 Participate in organisational management

Domain 5: Education and research

Standard 5.1 Deliver education and training

Standard 5.2 Participate in research

Standard 5.3 Research,synthesise and integrate evidence into practice

Activity: {Title of Activity:3}

Attendance

Expected attendance*

Sponsorship

Will sponsorship be sought*

Yes

What is the funding source for the sponsorship

How will sponsorship of the activity be acknowledged?

Describe how the educational content was developed free of commercial influence

Promotion

How will the program be promoted?*

Activity: {Title of Activity:3}

Program Details

Please provide information for each session or topic covered in the program (e.g. each CE lecture presentation, each topic in seminar program)

Click ‘add entry’ to add details for each session or topic in your program. PLEASE NOTE: you can add multiple sessions. When you have completed entry of the first session click ‘SUBMIT” and then ‘add entry’ to enter a subsequent session.

Program details

Session topic	Learning Objectives	Enter presenter name(s) and list conflicts of interest	Presenter’s title and position	CPD Activity Group	Duration	Actions

There are no Entries.

Maximum number of entries reached.

Activity: {Title of Activity:3}

Will a standard evaluation form be suitable?*

Yes

Please upload a draft of your own evaluation form*

Max. file size: 100 MB.

Name of person responsible for providing evaluation report*

First Last

Email of evaluation report representative*

Phone number of evaluation report representative*

Estimated date evaluation report will be sent to AdPha*

DD slash MM slash YYYY

Would you like a copy of your application emailed to you?

Please enter your email address and you will be sent a copy