Application Cover Sheet for Standard Events Sponsored by SOPHE

Transcription

Society for Public Health Education
Multiple Event Provider Number DC007
Application Cover Sheet
for
Standard Events Sponsored by SOPHE
Name of Event: A Call to Action: Matching SOPHE Membership Expertise with CDC’s National Tobacco CPPW
Tobacco-Funded Communities
Date of Event:
December 16, 2010
Name of Sponsoring Organization(s):
Society for Public Health Education;
Contact Person:
Nicolette Warren, MS, CHES
Address:
10 G Street NE, Suite 605
City:
Washington
State:
DC
Zip:
20002
Telephone:
(202) 408-9804
Fax:
(202) 408-9815
E-Mail: nwarren@sophe.org
Please check to make sure that the following have been included in the application:
A completed Distance Learning Event Cover Sheet
The completed Distance Learning Event Application Form
The Distance Learning Event Brochure-Must include appropriate wording for CHES
credit
Evaluation Tool(s) to be used (individual sessions and program if different)
Within 30 days following the event you must complete and return the Provider Event Report Form and
required paperwork to the chapter continuing education chair or designated person. If a National event to
the National Office.
After the application has been approved and a CE number assigned, the chapter or National CE contact will
provide:


Participant Roster form
Certificate of Attendance
Standard Event Application Form
for CHES Continuing Education Credits
Directions:
 Complete all of the following information and attach the required materials as listed on the Distance Learning
Event Application Cover Sheet.
 Return the completed form(s) to the CE Committee Chair at least 30 days before the Event.
 There must be a minimum of one (1) CHES on the planning committee and the event must be at least one
hour in length.
 Calculate the total number of Continuing Education Contact Hours: Count the total hours for the event
including all sessions but not including welcoming remarks, breaks, exhibits, poster sessions, meals, and
receptions. This will be the rough number of hours and should be rounded to the closest quarter-hour. For
example: two hours and fifteen minutes = 2.25 CECH, two hours and ten minutes = 2.25 CECH, two hours
and thirty-five minutes = 2.5 CECH, and two hours forty-five minutes = 2.75 CECH.
 National Events will be given a National CE Event number once the completed materials are received and
approved by the CE Committee. Chapter Events should be given a Chapter CE Event number when received
and approved by the Chapter CE Committee.
Part I Provider Information:
Organizing name:
Address:
10 G Street NE, Suite 605
City:
Washington
State:
DC
Telephone:
(202) 408-9804
Fax:
(202) 408-9815 E-mail: nwarren@sophe.org
Contact person:
Title:
Director of Health Equity
Address (if different):
Phone/Fax/E-Mail (if different):
Zip:
20002
Part II Event Planning Committee (must include at least one CHES):
Member:
CHES #: 10135
Organizational affiliation:
Member:
Rosemarie Matulionis
CHES #:
Organizational affiliation:
Member:
Meaghan McHugh
CHES #:
Organizational affiliation: Society for Public Health Education
Member:
Laura Boyle
CHES #:
Organizational affiliation: Society for Public Health Education
(Use separate sheet to list additional planning committee members)
Part III Event Information:
Event title:
A Call to Action: Matching SOPHE Membership Expertise with CDC’s National
Tobacco CPPW Tobacco-Funded Communities
Date(s) of event:
December 16, 2010
Location of event:
Webinar [Web seminar]
Type of event:
 conference
 directed self-study
 seminar
x distance learning
 workshop
 other:
Maximum number of CECH (1 CECH = 60 minutes) attainable by an individual at this event (includes
conference, pre and post conference workshops but does not include poster sessions, business meetings, welcoming
remarks, breaks, receptions, and exhibits): 1.5
Briefly explain how the need for this event was determined.
SOPHE organized this webinar on tobacco prevention and control to provide information and training to public
health educators. SOPHE identified CDC officials and SOPHE members to discuss the Communities Putting
Prevention to Work project and resources. This single-session event will discuss evidence-based and successful
approaches to tobacco prevention and control. This timely event will assist health educators in their professional
development and increase their ability to serve as a resource person in health education. The presenter will cater
this webinar to the target audience of public health educators, and will provide examples of opportunities for
SOPHE members and chapters to implement evidence-based tobacco approaches.
Check the area(s) of Responsibilities for Health Educators that are met by the session(s) behavioral/learning
objectives. A single two-hour event need only address one Responsibility.
Assessing individual and community needs for health education.
Planning effective health education events.
Implementing health education events.
Evaluating effectiveness of health education events.
Coordinating provision of health education services.
Acting as a resource person in health education.
Communicating health and health education needs, concerns and resources.
Part IV. SOPHE Contact:
Please address all questions to and return all completed application materials and the Event Report Sheet after the
event to:
Name:
Title:
Director of Health Equity
Address:
10 G Street NE, Ste 605
City:
Washington
State:
DC
Zip:
20002
Phone:
(202) 408-9804
Fax:
(202) 408-9815
E-Mail: nwarren@sophe.org
Please attach:
 Event Brochure (Must include appropriate wording about CHES credit).
 Evaluation Tool(s) (sample of both session tools and program tool if different).
 Individual Session Application Form(s) one for each session at the event.

Within 30 days after the event the completed Event Report form must be sent to the Continuing
Education Chair. The Provider Event Report form requires the completed typed information:
 Final Roster Sheets
 Summary of the evaluations
 Number of participants obtaining CECH
 Number of CECH awarded in total
 Fees for the credit hours awarded.
Individual Session Application Form for CHES Continuing Education Contact Hours
Session Title: A Call to Action: Matching SOPHE Membership Expertise with CDC’s National Tobacco CPPW
Please include complete data for all presenters (use the reverse side for additional speakers)
Presenter # 1 Name: Rose Marie Matulionis, MSPH Current Position (Title): Senior Project Director
Organization:
Society for Public Health Education (SOPHE)
Work Address: 10 G Street, NE Suite 605
Daytime Phone/FAX: 2-408-9804/202-408-9815
Email: rmatulionis@sophe.org
Bio:
Ms. Matulionis is SOPHE’s Senior Project Director, managing the Communities Putting Prevention to
Work initiative funded by HHS. This funding supports SOPHE, as one of ten national organizations, to assist the
CPPW funded communities implement prevention policy focusing on obesity and tobacco prevention and control.
Prior to joining SOPHE, Ms. Matulionis served as the Executive Director of the Directors of Health Promotion and
Education from 1996 to 2010; and as the Program Director for the Association of Teachers of Preventive Medicine
from 1992-1996. Her work has included the Prince Georges County Health Department (MD), Office of Health
Promotion, the Vermont Department of Health Office of Health Promotion; and the Vermont Department of Health
and Human Services. Her areas of interest include prevention policy, implementation of evidence-based
interventions, and training the public health workforce. Ms. Matulionis has co-authored several publications,
articles, and curricula. She also serves as a trainer for community training related to competency-based policy skills,
Shaping Policy for Health.
Presenter #2 Name: Meaghan McHugh, MPH
Organization:
Current Position (Title): Project Manager
Email: mmchugh@sophe.org
Bio: Meaghan McHugh, MPH is the Project Manager for the Community Putting Prevention to Work (CPPW)
initiative, with funding provided by HHS. Prior to joining SOPHE, Ms. McHugh served as Senior Program
Coordinator for the Montgomery County (MD) Tobacco Use Prevention and Cessation Program. As a certified
tobacco addiction specialist, Ms. McHugh has provided group and individual cessation counseling to adolescents,
young adults and adults who wish to quit using tobacco. Before her work in tobacco control, Ms. McHugh has
served as Senior Program Manager for Health Promotion at Special Olympics, Intl., Director for the DodgeJefferson Healthier Community Partnership, a community-based organization in Wisconsin and Director of
Environmental Programs for the National Association of State Development Agencies. Meaghan McHugh received
her Bachelors Degree in Economics from Holy Cross College and Masters in Public Health from Johns Hopkins
University.
***************************************
Presenter #3 Name: Laura Boyle
Organization:
Current Position (Title): Project Director
Email: lboyle@sophe.org
Bio:
Laura Boyle is the Project Director of Media for the Community Putting Prevention to Work (CPPW)
initiative, with funding provided by HHS. Laura is a media specialist, seasoned writer, and senior editor of
publications, promotional materials, press releases, technical proposals, and reports. In addition to developing high
quality print materials, Laura has written and edited web copy for corporate websites as well as social media
channels. She has extensive experience in reaching target audiences with appropriate messages that are culturally
relevant and easy to understand. In addition, she has managed programs and projects with a regional or national
reach. She is adept at developing and implementing marketing and communication plans with clear, measurable
goals and deliverables. Laura has a master’s degree in public health and a master’s degree in international policy and
practice. A certified health education specialist, Laura has experience and knowledge of health topics such as
tobacco control and prevention, cervical and breast cancer, international health and development, child development
and fetal alcohol syndrome, health literacy, and reaching special populations.
***************************************
Presenter #4 Name: Rebecca Bunnell
Current Position (Title): Program Director
Organization: Center for Disease Control and Prevention/DACH/CPPW
Work Address: 3005 Chamble Tucker Road Atlanta, GA 30341
Daytime Phone/FAX: 770-488-2524
Email: rrb7@cdc.gov
Bio: Dr. Rebecca Bunnell is the Program Director at the Center for Disease Control and Prevention/DACH/CPPW.
***************************************
Behavioral Learning Objectives
By the end of the session, the participant will be able to: Here are the learning objectives of the webinar:
Participants will be able to:



Describe the Communities Putting Prevention to Work Project and new tobacco control
and prevention resources available
Identify at least two activities communities implementation targets for the CPPW Project
Communicate the importance of SOPHE’s role in the Communities Putting Prevention to
Work Project and activities for SOPHE members involvement
*********************************************************************************************
Webinar Agenda
Time
1:00 PM
1:05 PM
1:27 PM
1:49 PM
Activity
Welcome/Introduction
Presenter
Laura Boyle
Overview of Communities
Putting Prevention to Work
SOPHE’s Role in CPPW
Opportunities for SOPHE
Rebecca Bunnell
Rose Marie Matulionis
Meaghan McHugh
2:25 PM
members
Opportunities for SOPHE
chapters
Questions/Answers
2:30 PM
Adjourn
2:09 PM
Laura Boyle
A Call to Action: Matching SOPHE Membership Expertise with
CDC’s National CPPW Tobacco-Funded Communities December 16 | 1:00pm ‐ 2:30pm ET
_
Developed to inform SOPHE members and partners about the new initiatives around the CPPW grant provided by the Department of Health and Human Services. Speakers will present from 1:00pm‐2:25pm followed by a Q & A session. Presenters:  Rebecca Bunnell Program Director, CPPW, Centers for Disease Control and Prevention  Rose Marie Matulionis, MSPH Senior Project Officer, CPPW Initiative, SOPHE  Meaghan McHugh, MPH Project Manager, CPPW Initiative, SOPHE  Laura Boyle, MPH, CHES, MIPP Project Director for Media, CPPW Initiative, SOPHE Check out National Health Education Week 2010 resources @ www.sophe.org/nhew.cfm To Register: https://sophe.webex.com/sophe/onstage/g.php?t=a&d=966274013 Registration Password: Fall2010 Please note – If you are unable to attend this webinar, it will be recorded and available on SOPHE’s Continuing Education Self Study page at: http://www.sophe.org/webinars.cfm An application has been submitted to award up to 1.5 Continuing Education Contact Hours (CECH) for certified health education
specialists (CHES). SOPHE, including its chapters, is a designated multiple event provider of CECHs by the National Commission for Health Education Credentialing. **Fees apply for CHES credits S O C I E T Y F O R P U B L I C H E A L T H E D U C A T I O N 10 G Street, NE Suite 605 Washington, DC 20002 Phone: 202/408.9804 Fax: 202/408.9815 www.sophe.org Society for Public Health Education
A Call to Action: Matching SOPHE
Membership Expertise with CDC’s National
Instructions for Evaluating the Webinar
and
Requesting Continuing Education Credit
Your feedback is important to the Planning Committee and helps us continue to create
a training program that meets your needs. It also allows us to consider new
opportunities and content that adds value for participants.
If you wish to receive Continuing Education Contact Hours (CECH), you must complete
the necessary forms, and turn in your documentation with payment to the National
SOPHE office.
1. Complete and sign the evaluation form. You must answer all questions to
receive credit.
2. Mark the Participation Record indicating your attendance by placing an X in the
box on the matrix next to the session title. Total the number of credits you
earned in the column labeled “CECH” and write it is as the total credits for which
you are applying.
3. To receive credit, complete and sign the Continuing Education Form.
4. CECH Fees are applicable. The fee for this event (1.5 credit hours) is: $10.50
for National SOPHE members, $21.00 for non-members. Checks or credit card
(Visa, MasterCard, or Discover) payments will be accepted. Checks should be
made payable to SOPHE.
5. Mail or fax (preferred) the required items to:
SOPHE
Attn: A Call to Action: Matching SOPHE Membership Expertise with CDC’s National
10 G Street NE; Suite 605
Washington, DC 20002
(202) 408-9804 (202) 408-9815 FAX
A Call to Action: Matching SOPHE Membership Expertise with CDC’s National Tobacco CPPW Tobacco-Funded Communities
December 16, 2010
Continuing Education Form and Participation Record
Event # 01-155DL
If you are applying for Continuing Education Contact Hours (CECH) you must complete all of this form
and print and sign your name on the bottom of the overall evaluation form.
The following information is REQUIRED for ALL participants requesting Continuing Education
Contact Hours for CHES (please print):
Name:
Signature:
CHES #
Address
City, State and Zip:
Phone:
Fax:
Email:
Credit Card Payment Information:
Cardholder Name (if different from above):
Billing Address (if different from above):
City, State and Zip:
Method of Payment:
Visa
MasterCard
Discover
Credit Card Number:
Expiration Date
Signature of Cardholder:
Total: $
****************************************************************************
A Call to Action: Matching SOPHE Membership Expertise with CDC’s National Tobacco CPPW Tobacco-Funded Communities
X
(indicate participation by placing an “X” next to the session titles)
Time
CECHs
“X” Below
Tuesday, December 16, 2010
1:00-2:30
1.5
Welcome/Introductions
Laura Boyle
Overview of Communities Putting Prevention to Work
Rose Marie Matunlionis
SOPHE’s Role in CPPW
Meaghan McHugh
Opportunities for SOPHE members
Laura Boyle
Opportunities for SOPHE chapters
Rebecca Bunnell
TOTAL NUMBER OF HOURS REQUESTED for sessions attended
(Participant to Complete)
(Note: Round to nearest .25)
A Call to Action: Matching SOPHE Membership Expertise with CDC’s
National Tobacco CPPW Tobacco-Funded Communities
Evaluation Form
Date: December 16, 2010
Time: 1:00 PM -2:30 PM
Event Number: 01-155DL
1.5 CECH for CHES
Please complete this evaluation. If applying for continuing education credits you MUST complete all questions.
For each of the following questions, mark (X) the column that best represents your opinion regarding this session.
Use the rating scale of 1-5 (1=strongly disagree, 5=strongly agree)
Learner Objectives
As a result of this session, I am able to:
1.
Strongly
Disagree
1
2
Neutral
3
4
Strongly
Agree
5
Describe the Communities Putting Prevention to Work Project and new tobacco
control and prevention resources available
Identify at least two activities communities implementation targets for the CPPW
Project
Communicate the importance of SOPHE’s role in the Communities Putting
Prevention to Work Project and activities for SOPHE members involvement
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Rose Marie Matulionis demonstrated mastery of the topic.
Rose Marie Matulionis was an effective presenter.
Meaghan McHugh demonstrated mastery of the topic.
Meaghan McHugh was an effective presenter.
Laura Boyle demonstrated mastery of the topic.
Laura Boyle was an effective presenter.
Rebecca Bunnell demonstrated mastery of the topic.
Rebecca Bunnell was an effective presenter.
The session was timely in terms of current public health and health
education practice.
Please answer the following questions.
1.
Suggestions for presentation improvement such as length, audiovisuals, handouts, materials, or what you
would change about this session.
2.
Additional Comments/Observations
Thank you for your feedback!
Society for Public Health Education,
10 G St. NE, Suite 605, Washington, DC 20002-4242
Certificate of Attendance
A Call to Action: Matching SOPHE Membership
Expertise with CDC’s National Tobacco CPPW TobaccoFunded Communities
December 16, 2010
EVENT # 01-155DL
NCHEC PROVIDER NUMBER DC0007
Name of Participant:
CHES Number:__________________________________
Category I Contact Hours Completed:
SOPHE is designated as a provider of continuing education contact hours in health education by
The National Commission for Health Education Credentialing, Inc.
This program is a designated event for CHES to receive up to 1.5 Category I CECH in health education.
__________________________________________
SOPHE CHES Representative
Society For Public Health Education, Inc.
Provider Event Report Form
(This form is to be submitted to the National SOPHE Office, with the enclosures listed below, NO LATER
THAN 30 DAYS FOLLOWING THE EVENT. A duplicate of this form without fees must be sent to the
National CE Committee Chair. A late fee of $50 will apply to all reports received later than 30 days.)
NCHEC Provider Number: DC0007
I.
Date of Report:
Provider:
Address:
Contact Person:
Phone:
II.
Event Number:
FAX:
01-155DL
Email:
Event Date(s): December 16, 2010
Event Title: A Call to Action: Matching SOPHE Membership Expertise with CDC’s National Tobacco
CPPW Tobacco-Funded Communities
Location:
Webinar
#CECHs approved: 1.5
# CHES receiving CECH in attendance:
Total # CECHS received by CHES at event:
(multiply # approved X # CHES in attendance)
III.
Attach a completed final typed roster form. Please use the Roster Form that is supplied. Duplicate the
pages as many times as needed for your complete participant list.
IV.
Please attach a summary of the evaluation conducted at the conclusion of the event.
V.
Fee (check made payable to SOPHE):
$ 1.50 X
(Total #CECHs received - II line 5)
Signature of Event Coordinator:
=
$
(amount enclosed)
Post Event - Participant Roster Form
Event Date: December 16, 2010
Event Number: 01-155DL
Event Title: A Call to Action: Matching SOPHE Membership Expertise with CDC’s National Tobacco CPPW
Number of CECH assigned to the event: 1.5
Total Number of CECH earned by CHES at the Event:
CHES #
Last Name
First Name
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
This form may be duplicated as needed.
CECH Earned
CECH Event Review Form
Name of Reviewer:
Email Address:
Date of Event: December 16, 2010
# CECH for CHES Requested:
1.5
Review Due Date:
Please check YES or NO to indicate whether you believe each of the review criteria has been met satisfactorily for
the event as a whole and for each individual session. Add any comments in the space provided.
Overall Program:
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
1. Membership on the planning committee meets requirements.
2. Appropriate wording appears on event materials.
3. Needs assessment has been conducted.
4. Agenda includes time frames.
5. Draft copies of evaluation forms are appropriate for this event.
Comments:
Individual Sessions:
Session: Overall Evaluation only
Yes
No 1. Responsibilities/Competencies addressed.
Yes
No 2. Presenter information is appropriate and complete.
Yes
No 3. Objectives included.
Yes
No 4. Evaluation tool is appropriate for session.
Comments:
I approve this event for
CECH for CHES.
CECH for CHES, contingent on the following:
I do not approve this event for CECH for CHES.
Please email/fax/send this form to:
Nicolette Warren
10 G St., NE Suite 605
P: (202) 408-9804 F: (202) 408-9815
Email: nwarren@sophe.org
Name of Reviewer:
Email Address:
1.5
Review Due Date:
Overall Program:
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Comments:
Yes
Yes
Yes
Yes
Comments:
CECH for CHES.
Nicolette Warren
P: (202) 408-9804 F: (202) 408-9815
Name of Reviewer:
Email Address:
1.5
Review Due Date:
Overall Program:
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Comments:
Yes
Yes
Yes
Yes
Comments:
CECH for CHES.
Nicolette Warren
P: (202) 408-9804 F: (202) 408-9815

Application Cover Sheet for Standard Events Sponsored by SOPHE

Transcription

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