Apply for Joint Providership MPhA Joint Providership ApplicationPlease complete the following application to submit your request for joint providership with the Maryland Pharmacists Association. This application must be submitted at least 30 days prior to the planned educational activity. Please also keep in mind that MPhA may only accredit Knowledge-Based activities at this time. All sections must be completed for the application to be reviewed and considered. Incomplete applications will not be accepted for any reasons.Hosting Organization's InformationHosting Organization's NameHosting Organization's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican 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 RicoQatarRéunionRomaniaRussian FederationRwandaSaint 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 TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Hosting Organization's Mission Statement(Required)Primary Contact Name(Required) First Last Primary Contact Title(Required)Primary Contact Email Address(Required)Best Contact Number(Required)Activity Information- SINGLE CPE ActivityPlease provide detailed information for the activity or event requiring accreditation. If you are only seeking accreditation for one activity, complete this section only. If you are seeking accreditation for multiple activities, please skip to the next section.Activity TitleActivity DescriptionActivity Format Live Home Study Webinar Select AllTarget Audience Pharmacists Technicians Select AllNumber of contact hours requested1hr= 1.0 contact hourProposed Date(s) of ActivityEstimated number of participantsLearning ObjectivesPlease list the learning objectives for this activity. Learning Objectives may be similar for both pharmacists and technicians. Use Bloom’s Taxonomy as a reference to craft your learning objectives. This is located on MPhA’s CPE Resource Page.Applicable ACPE Topic Designators 01: Disease State Management/Drug Therapy – activities that address drugs, drug therapy, and/or disease states. 02: HIV/AIDS – activities that address therapeutic, social, ethical, or psychological issues related to the understanding and treatment of patients with HIV/AIDS. 03: Law Related to Pharmacy Practice – activities that address federal, state, or local laws and/or regulations affecting the practice of pharmacy. 04: Pharmacy Administration – activities that address topics relevant to the practice of pharmacy that include the economic, social, administrative and managerial aspects of pharmacy practice and health care. 05: Patient Safety – activities that address topics relevant to the prevention of healthcare errors and the elimination or mitigation of patient injury caused by healthcare errors. 06: Immunizations – activities related to the provision of immunizations, i.e., recommend immunization schedules, administration procedures, proper storage and disposal, and record keeping. This also includes review for appropriateness or contraindication and identifying and reporting adverse drug events and providing necessary first aid. 07: Compounding – activities related to sterile, nonsterile, and hazardous drug compounding for humans and animals. This includes best practices and USP quality assurance standards, environmental testing and control, record keeping, error detection and reporting, and continuous quality improvement processes. 08: Opioids/Pain Management/Substance Use Disorder – activities that address any component regarding the treatment and management of pain, including the prescribing, distribution and use of opioid medications, and/or the risks, symptoms, and treatment of opioid misuse/addiction. 99: Additional Topic Areas – activities related to topics relevant to the practice of pharmacy not included in the classifications of the topic designators 01-08. As the ACPE-accredited provider of continuing pharmacy education, MPhA retains the right to change the topic designator if necessary.Does this activity require a fee for participation?Yes, a one-time chargeYes, a subscription that is a recurring fee, typically monthly or annuallyYes, a membership that requires a regular payment to be part of the organization.NoActivity Information- MULTIPLE CPE ActivitiesThis section is required for organizations seeking accreditation for multiple activities or events. Please provide the necessary details for each additional activity that requires individual accreditation.Activity Title(s)Activity Date(s)Target Audience(s) Pharmacists Technicians Select AllEstimated number of participants (per activity)Activity Format Live Home Study Webinar Select AllNumber of contact hours requested (per activity)1hr= 1.0 contact hourLearning ObjectivesPlease list the learning objectives for this activity. Learning Objectives may be similar for both pharmacists and technicians. Use Bloom’s Taxonomy as a reference to craft your learning objectives. This is located on MPhA’s CPE Resource Page.Does this activity require a fee for participation?Yes, a one-time chargeYes, a subscription that is a recurring fee, typically monthly or annuallyYes, a membership that requires a regular payment to be part of the organization.NoAcknowledgment of TermsPlease review the following terms before submitting this agreement. By agreeing, you confirm that all information provided is accurate and acknowledge your responsibilities as the hosting organization in partnership with MPhA. If accepted, MPhA will follow up with an official Letter of Agreement and a Joint Project Task Schedule within three business days.By submitting this form, the hostin organization acknowledges and agrees to the following: By submitting this form, the hosting organization acknowledges and agrees to the following: I acknowledge that I have been provided with, have read, and agree to the terms outlined in the Joint Providership Policies and Procedures. The hosting organization agrees to follow all MPhA joint providership policies, including content review, ACPE compliance, and deadlines. MPhA retains final authority over educational content, including the right to adjust topic designators to meet ACPE standards. The hosting organization is responsible for assessing educational needs, coordinating faculty, and ensuring content relevance to the target audience. All fees, timelines, and accreditation procedures in this agreement are binding and subject to MPhA’s approval. Select AllPlease type your full name to sign this Joint Providership Agreement(Required)By typing your full name, you confirm that the information provided in this agreement is accurate and that you agree to the terms and conditions provided above.Date(Required)
