Application for CPD ApprovalPlease complete this form (referring to the guidance notes here) and return it with the relevant supporting documents and fee (where applicable) either by email, to cpd@rcoa.ac.uk, or by post to the address below. Please allow up to four weeks for your application to be processed.

Please complete the information below as you would like it to appear on the ‘Approved courses’ section of the RCoA’s CPD Online Diary.

Event title:

Start date: End date:

Providing organisation’s name, postal addressand website details / hyperlink to event (if applicable):

Venue name andlocation:

Lead organiser:(must be a clinician of consultant status, or approved SAS trainer)

Fee details:Nominated contact:(name, telephone and email details)

Nominated commercial sponsor(s):

Educational informationTarget audience (please mark with an ‘X’ as appropriate):

Career grades Training grades Non-medical

Target audience – geographical area (please mark with an ‘X’ as appropriate):International National Regional Local

How and where do you intend to advertise your event?

All events approved for CPD are included in the RCoA CPD Online Diary and added to the College website. Please mark this box with an ‘X’ if you would NOT like your event to be featured in this way.

Royal College of AnaesthetistsChurchill House, 35 Red Lion Square, London WC1R 4SGTel 020 7092 1500 Email cpd@rcoa.ac.uk Website www.rcoa.ac.uk/revalidation-cpd

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Please state the overall aim of the event and topics to be covered:

Please state the anticipated learning outcomes of the event:

1

2

3

4

How many CPD credits are you applying for?(Please note each credit equates to one hour of educational content. The number of hours should exclude break times.)

What teaching methods will be used? (Please mark with an ‘X’ as appropriate):

Lectures Tutorials Demonstrations Practicals Workshops

Discussion groups

e-Learning MCQs Individual performance

review

Other (please specify)

Have you held a similar event previously? If yes, please provide details below.

Has this event been previously approved for CPD by another Medical Royal College?(If so, please provide further details below.)

RCoA CPD Matrix

The CPD Matrix is designed to assist anaesthetists and appraisers in their appraisal discussions and to help guide individual CPD requirements as part of the personal development plan. As many doctors use the Matrix codes to log their CPD activity, and to assist individuals in selecting appropriate CPD, the RCoA encourages event providers to map their programme content to the Matrix. The RCoA views the allocation of codes as a very helpful guide but not an absolute requirement to allow CPD approval to be awarded.

Royal College of AnaesthetistsChurchill House, 35 Red Lion Square, London WC1R 4SGTel 020 7092 1500 Email cpd@rcoa.ac.uk Website www.rcoa.ac.uk/revalidation-cpd

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Supporting documents for CPD approval

Please include the following supporting documents (marked with an ‘X’ if submitted). The first three items are mandatory.

Event programme detailing topics mapped to the CPD Matrix (where appropriate).

List of speakers and their post/title e.g. Consultant; Senior Lecturer; ST4 etc.

A copy of the delegate evaluation form.

Event learning materials (where applicable).

Pre- or post-course educational activity e.g. reading lists, MCQ papers (where applicable).

Conflict of interest

Please provide details of any conflicts of interest below. A conflict of interest exists where an individual involved in the development or delivery of CPD has an interest in a commercial or other organisation which may compete with the individual’s duty to act independently.

Type of organisation

What is your organisation type? (Please mark with an ‘X’):

Commercial Non-commercial / not for profit

For commercial organisations providing events an application and evaluation fee of £1,320 (incl. VAT) per event is payable. Please contact cpd@rcoa.ac.uk for further details, or to make a payment.

CorrespondencePlease include your contact information for future correspondence, if different from the information already provided.Name:Email:

Address:

Tel:

Signed.............................................................................. Print Name.................................................................................

Royal College of AnaesthetistsChurchill House, 35 Red Lion Square, London WC1R 4SGTel 020 7092 1500 Email cpd@rcoa.ac.uk Website www.rcoa.ac.uk/revalidation-cpd

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