CPD Application Form CPD Application Form 1Course details2Educational Details / Course Content3Financial and Conflict of Interest Declaration4FFLM website5Declaration on Conflict of Interest Course DetailsCourse Name** Start Date** DD slash MM slash YYYY End Date** DD slash MM slash YYYY Venue . Location** Fee(s) to be charged to the delegates:* Number of hours (excluding break times)* Providing Organisation* Course Organiser** Contact name** Date of previous course* DD slash MM slash YYYY Contact E-mail** Correspondence Details (if different from above)Name Email PhoneAddress Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Educational Details / Course ContentPlease provide details of primary purpose of event*Please list the Learning Objectives for the event below. The objectives should reflect measurable learning contents and be relevant to the target audience*How will the educational content of the event be evaluated by participants?*The following questions need to be included in the evaluation 1. Were the printed learning aims and outcomes of the course met? 2. Was there any bias or conflict of interest evident in the course 3. Was the instructor/speaker organised and knowledgeable? Attendance certificates*Please confirm certificates of attendance will be issued and agree to supply to the participant or the Faculty, on request. Yes No Target audience*Please tick all that apply Medico-legal Advisers Forensic Medical Practitioners Coroners Others Please state other* Financial and Conflict of Interest DeclarationName(s) of any companies with a commercial interest in the event and details of the role taken by these companies (i.e. sponsors or content providers):Company Role Company Role Company Role Company Role Is the providing organisation*Please tick all that apply Not for profit? A profit / commercial company Operating with an unrestricted grant from a sponsor? A Registered Charity Charity No: Are there any conflicts of interest*Please tick all that apply Yes No Please provide details of any potential conflicts of interest below specifying nature of potential conflict, steps taken to manage conflict and 3rd parties involved. Guidelines on conflicts of interest can be found at the back of this form. Please continue on a separate sheet if required. FFLM WebsitePlease provide further details of the course for publishing on the event page at http://fflm.ac.uk/events/ Link to course details on your website Text you would like to appear on the event page (e.g. course objectives, how to apply, etc)*Deadline for booking Contact name/details for delegates Programme upload*Max. file size: 8 MB.Please attach electronic formsAdditional Documents* Drop files here or Select files Max. file size: 8 MB. Speaker biographies (bios to include example of teaching and experience minimum of 120 words) , feedback from previous courses etcCost* Start Date DD slash MM slash YYYY Start time : Hours Minutes AM PM AM/PM End Date DD slash MM slash YYYY End time : Hours Minutes AM PM AM/PM Location Submission checklistPlease ensure you have: Include a full programme of the meeting, including an hourly breakdown and details of the sessions Include a complete list of the speakers and include their CVs or a short biography, for each, listing the posts they hold, where they are based and what qualifications and experience they have, particularly in relation to the topic to be presented. Completed all sections in this application form, and sign the “declaration of conflict of interest” paid the course submission (or resubmission) fee For courses that will be running for the 2nd or 3rd time, please provide summary feed back receive from previous course participants PLEASE NOTE: Organisers of approved events are required to: keep a record of the names of the people who attended provide attendance certificates to participants provide evaluation forms to the delegates and the FFLM on request (up to 2 years after the event has taken place) FFLM Conflict of Interest Guidelines for CPD Course OrganisersThe following guidelines are not exhaustive but are intended as guidance for course organisers when applying for FFLM accreditation of CPD activity. If the organiser or any of the speakers have any potential conflicts of interest (vested interests) these must be declared on the CPD application form. It should be noted however that potential conflicts of interest will not, in themselves, prevent a course from receiving CPD accreditation provided that the primary purpose of the event is demonstrably educational and any sponsorship or commercial interests are shown not to be influencing the structure or content of the event. A conflict of interest exists where an individual or organisation engaged in the provision of CPD has an interest in a commercial or other organisation which may compete with the individual’s duty to act independently in the provision of the educational activity. Conflict of interest may occur in relation to any of the following links with a third party company or organisation where that body has a commercial interest in the CPD activity being held, for example as a provider of products or services that might be of interest or relevance to the course attendees or that might want to influence the views of target audience. Such a link may be direct, or through an immediate family member A current or recent ownership interest (including holding stock or shares) of the organizers or speakers in such a company Employment (extending to Board positions) or contract to provide services (including acting in a consultative or advisory capacity) Receipt of financial or other support (including funding research, hospitality, travel or accommodation costs) provided to organizers or speakers or organisations in which they may have an interest (such as companies, departments or charities) Payment for a representative of the company to attend or speak at the CPD event Sponsorship of the event or regular sponsorship of other events held by the organisers Any other commercial arrangement that might benefit the course organisers or speakers, either directly or indirectly Declaration on Conflict of InterestI/We have read and understood the FFLM guidelines regarding conflict of interest. I/We have declared and submitted all information about any potential conflict of interest in accordance with the guidelines. I/We agree that I/we have provided all of the requested information regarding the sponsorship of the applied for event/s and have been accurate about the status of our organisation (not-for-profit/for-profit). THIS DECLARATION MUST BE COMPLETED AND SIGNED BY THE COURSE ORGANISER A* I agree to the declarations and privacy policy.B* Please confirm you have fully complete all sections. Failure to do so will delay the review of your applicationDate DD slash MM slash YYYY EmailThis field is for validation purposes and should be left unchanged.
