Submit your Faculty Agreement!

MPhA CPE Faculty Agreement

Please complete this faculty agreement to confirm your participation and compliance with MPhA’s accreditation requirements for educational activities for pharmacists and technicians.

MPhA Online Faculty Agreement

Welcome to MPhA’s online faculty agreement! Please review and complete each section, confirming that all information provided is accurate and agreeing to the outlined terms. Unless otherwise stated, all MPhA education is usually accredited for both pharmacists and technicians.

Contact Information

Your Name(Required)

First Last

Email Address(Required)

Best Contact Number(Required)

Credentials

PharmD

RPh

PhD

Select all that apply.

If your credential is not listed above, please specify here:

Job Title(Required)

Employer(Required)

Please include a short bio(Required)

Please include a short bio, limited to no more than 6 sentences, highlighting your professional background and expertise.

Please upload your Resume/CV(Required)

Max. file size: 256 MB.

Please upload your headshot(Required)

Max. file size: 256 MB.

Please note that this image may be used in MPhA’s social media and marketing materials for the program on which you will be presenting.

Activity Information

Please provide a brief description of this learning activity.

Activity Title(Required)

Activity Description(Required)

Activity Setting(Required)

Live

Home Study

Webinar

Activity Length(Required)

Example: 1 hour 30 minutes

Learning Objectives(Required)

Please 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.

Current State of Practice(Required)

What does the current state of practice look like? (At least 3-4 sentences are required)

Better or Best State of Practice(Required)

What does a better or best state of practice look like? How might this activity help pharmacists/technicians get there? (At least 3-4 sentences are required)

Financial Relationship Disclosures

As the speaker and in control of the content, this section is for you to disclose any and all financial relationships with any ineligible entities (ineligible entities are companies that sell/market or distribute products to be used on or by patients) within the past 24 months. This would include any consulting fees charged, honoraria, stock ownership, or other forms of compensation. If you have no disclosures, please skip this section and check off the certification field below. If you have more than two financial relationships to disclose, please complete the supplemental financial relationship disclosures form.

Company Name

Description of role/services

Nature of Relationship

Dates of relationship

Company Name

Description of role/services

Nature of Relationship

Certification and Signature

I certify that all media materials, including but not limited to handouts and presentation slides are of original content and not subject to copyright release by another party. If all or a portion of media materials include information from copyrighted sources, the presenter agrees to provide appropriate evidence of copyright release and agrees to reference such sources in the media materials. I agree to hold MPhA harmless from any action which may result from my use of materials, permission for which has not been appropriately obtained from the holder of a copyright, and/or which are not appropriately referenced.

I certify that I have viewed the required self-guided faculty orientation video prior to completing this agreement.(Required)

Yes

Please type your full name to sign this faculty 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.