1. Please list your DHA Directorate, Market, MTF, and/or Organization. *

2. Please list your military or government POC and contact information. *

3. Please list the overall number of events planned for FY22. *

4. Please list the planned dates/date ranges for your CE/CME activities in FY22. *

5. How many of your activities will be live? *

6. How many of your activities will be home studies/enduring? *

6A. If you do have home studies/enduring activities, where will they be housed?

7. How many of your activities will be one day? *

7A. What is the estimated number of CE/CME hours you plan to offer for each activity? *

8. How many of your activities will be more than one day? *

8A. What is the estimated number of CE/CME hours you plan to offer for each activity? *

9. How many of your activities will use the same content and be offered more than once? *

10. What topic(s)/theme(s) will your course(s) address in FY22? *

11. Have you consulted with the respective center of excellence (i.e. Hearing Center of Excellence, Vision Center of Excellence, etc.) or DHA Clinical Communities regarding the topics/themes of your course(s) for consistency and collaborative purposes? *

Yes

No

12. Do you have any recommendations for topics/speakers for the CY22 Clinical Communities Speaker Series (CCSS)? If so, please provide the POC(s) name and contact information below. *

13. Do you have any recommendations for moderators for the CY22 CCSS? If so, please provide the POC(s) name and contact information below. *

14. Do you have any speaker recommendations for opening and/or closing remarks for the CY22 CCSS? If so, please list the POC(s) name and contact information below. *

15. Are there any new/emerging health care topics you would like to learn more about? If so, please list them below *

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