CPD Application Form for FFLM Courses

Phone

This field is for validation purposes and should be left unchanged.

Course Details

Course Name**

Start Date**

End Date**

Venue location*

Number of hours (excluding break times)*

Date of previous course

Educational Details / Course Content

Please 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*

I confirm that the learning objectives are specifically defined and will match the course content*

I Confirm

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
Examiners
Forensic Medical Practitioners
Coroners
Others

I confirm that the course is appropriate for my target audience*

I Confirm

Please state other*

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.

Programme for the day

Max. file size: 16 MB.

Speaker Bios*

Max. file size: 16 MB.

Additional comments

Date

Consent*

I hereby give my explicit consent to the processing of my personal data in accordance with the Data Protection Act 2018 and the FFLM Privacy Policy.

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