DeBakey CV Education Course Application

Thank you for your DeBakey CV Education course request.

Please take a few minutes to fill out this course form so the DeBakey CV Education team knows how to best serve you.

Contact Information

First Name * Middle Initial Last Name * Affiliation/Department * Street Address * Suite City * State * AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code * Email Address * Primary Phone Number * Other Phone Number Will you be the primary contact? * Yes No

Please provide contact information of the person that will be assisting you with this activity, if applicable. First Name Middle Initial Last Name Email Address Primary Phone Number Other Phone Number

Course Information

Course Topic * Proposed Course Title * Proposed Start Date * Proposed End Date * Proposed Location (list venue and room location) * Proposed Course Director (First and Last) * Course Synopsis (overview, what makes course unique, why course is needed) * Target Learners * Fellows Mid-levels Nurses Patients Physicians Researchers Residents Other If Other, please specify Target Learners' Specialty * Cardiac Cardiology Vascular CV Anesthesiology Interventional Radiology N/A Other If Other, please specify Will members of industry, such as medical devices and pharmaceuticals, be targeted learners for this program? * Yes No Teaching Methodology * Didactic/Lecture Panel Discussion Case Studies Demonstration Hands-On Exhibit Virtual Learning Other If Other, please specify Is this the first time this activity is being held? * Yes No Is this or will this be a recurring activity? * Yes No Continuing education (CE) credits to be sought * None CME CEU Other If Other, please specify Entity Sponsorship * Houston Methodist Industry Society Other If Other, please specify Is another institution or organization besides Houston Methodist involved in the educational panning or curriculum development? * Yes No Who will perform the planning and coordination of this event? * DeBakey CV Education CME Office Houston Methodist Entity Other If Houston Methodist Entity, please specify If Other, please specify Who develops the budget? * DeBakey CV Education HMH Departmental Industry Other Will funds from DeBakey CV Education be required? * Yes No Will commercial support (such as educational grants or in-kind donations) be solicited? * Yes No Please identify the companies that will be solicited for support, if applicable Will companies be allowed to purchase exhibit space? * Yes No Please identify the companies that will be solicited for exhibit space and accompanying fees, if applicable.

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