Sample Documents

Continuing Education (CE) Providers can refer to the following sample documents.  They are intended to help providers develop their own forms and processes to use when administering their own CE programs.  Providers can modify these documents to best fit their needs.

If you’re not currently using one of the documents required, you’re encouraged to develop the document and begin using it in your program before applying or reapplying for approval.

Sample Documents:
Note: Providers only need to submit the samples that are applicable to their program.

• Sample Job Responsibilities
• Sample Meeting Minutes
• Sample Goals
• Sample Needs Assessment Survey
• Sample Course Objectives
• Sample Affidavit of Image Authenticity
• Sample Publicity Brochure
• Sample Publicity — Flyer
• Sample Publicity — Half Page
• PACE Logo Guidelines
• Sample Course Evaluation
• Sample Attendance Verification Form
• Sample Course Roster
• Sample Guidelines for Commercial Support
• Sample Financial Supporter/Sponsor Agreement
• Sample Conflict of Interest Disclosure
• Sample Patient Consent Form
• Sample Emergency Plan
• Sample Joint Sponsorship Letter of Agreement
• Joint Program Provider Responsibliity Checklist
• Annual Report