1 Start 2 Complete A UKHCCEC staff member, activity director, moderator or other qualified designee should complete this form. Activity Title * Activity Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20232024202520262027 CE Representative * Provide the First and Last Name of the individual completing this form. Number of Speakers to Review 1 2 3 4 Speaker * First and Last Name Presenter disclosed relevant financial interest via handout? * Yes No Speaker Checklist * Used the generic term when referring to drugs If used a trade name, compared and contrast several products Presentation was objective and fairly balanced Participants were actively involved in the learning process through group discussion, Q and A, posttest, case study, simulation and/or problem-solving exercises Additional Comments Representative on Site * Yes No Supporter Involvement * Yes No Did the program include an ancillary activity? * Assess ancillary activities include: exhibits, advertising, promotion, non-accredited activities, and social events. Accreditation standards require ancillary activities to be held outside the education space, or if held in the same educational space, to be separated by a 30 minute interval between the accredited activity and the ancillary activity. Yes No Additional Comments Leave this field blank
