ISHLT Academy

CORE COMPETENCY COURSE

Application Form

Please review the following before completing this form:

Standards for REPEAT Core Competency Courses

Standards for NEW Core Competency Courses

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Applicant Information

Date of Request: Click or tap here to enter text.

Your Name: Click or tap here to enter text.

Your Email: Click or tap here to enter text.

Your Phone: Click or tap here to enter text.

Name of Committee/Council you are submitting on behalf of: Click or tap here to enter text.

Are you an Officer or Workforce Leader of the above Council? ☐Yes ☐No

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ISHLT Academy Core Competency Course Information

Title of proposed Core Competency Course: Click or tap here to enter text.

Is this proposed as a REPEAT of a previously presented Core Competency Course (minor modifications and updates to content and new speakers permitted): ☐Yes ☐No

If NO, has the ISHLT Board already approved a Core Competency Curriculum Document to serve as the basis for developing the proposed Course? ☐Yes ☐ No

If NO, has a Core Competency Curriculum Document that will serve as the basis for developing the proposed Course been submitted to the Education Committee for approval? ☐Yes ☐No

In association with what Annual Meeting do you wish to have this Core Competency Course take place? Click or tap here to enter text.

Please describe the intended target audience for this course (specify which healthcare professionals, which specialties, which experience levels):
Click or tap here to enter text.

At which ISHLT Annual Meeting do you wish to have this Core Competency Course take place?
Click or tap here to enter text.

Names of Proposed Chair and Co-Chair (must be ISHLT members; may not be current Council Officers; must have been approved by the Council Officers)
Chair: Click or tap here to enter text.

Co-Chair: Click or tap here to enter text.

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Course Format and Development

The Education Committee has developed a specific format to which all Core Competency Courses must

adhere. These are outlined in the Standards for Core Competency Courses. If your application for a Core

Competency Course is approved by the Education Committee, the Director of Education and Meetings will provide the Chair and Co-Chair with the Standards and Template for use in developing the course content.

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Continuing Education Credit

What type(s) of continuing education credit is / are being requested?

☐AMA PRA (physician)

☐ACPE (pharmacist, pharmacy technician)

☐AANC (nurse)

☐ABTC (coordinator/CEPTC credit)

☐Other: Click or tap here to enter text.

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For ISHLT Staff Use Only

Anticipated total expenses: Click or tap here to enter text.

Anticipated total revenue: Click or tap here to enter text.

Approved: ☐Yes ☐ No

Comments: Click or tap here to enter text.