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New E-Learning Request, form #1

Use this form to submit a new e-learning request to CED before you begin developing or purchasing any materials. A CED team member will follow up with you. If you would like help completing this form, contact Liz du Plessis (eac506@health.missouri.edu)

1. Education topic and brief description: *This question is required.

2. Approvals: Has this education plan been approved by your leadership? *This question is required.

3. Please enter the name and position of the leader:

Please obtain approval before submitting this form.

3. How will the audience access the education? Select all that apply. *This question is required.

Online
In-person
Not sure
Other - select to add description

4. Other ways the audience will access the education:

4. Why is this education needed? Select all that apply. *This question is required.

To provide reference or educational materials that can be accessed on-demand
To document that staff have completed the education
To address a regulatory requirement.
To support a behavior change.
Other - select to add a description

5. What is the standard? What regulatory body is requiring it?

5. Describe the desired behavior change.

5. Describe why this education is needed.

5. Who is the audience? Describe the target audience for this education (such as inpatient pharmacists, inpatient nurses, inpatient techs, etc.) *This question is required.

6. When should the education be launched? Select the desired launch date: *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

7. Requester contact information *This question is required.

Your name:
Job title & department:
Email address:
Phone number:

8. Comments or questions? Use the space below.

To be completed by CED

Dates
Form 1 received:
Followed-up with requester:
Presented at meeting:

Pre-approvals
Names & dates:

Notes
Instructional Designer:
Tech Team:
Clinical Education Team: