Grand Rounds Request Form

If you are interested in hosting a grand rounds, please submit the form below.

*Contact Person:
Site Name:
Site Address:
Site Address:
City: State:
ZIP:
Phone: Fax:
*Contact E-mail:

Please list three available dates

Date: Time:
Date: Time:
Date: Time:

Please list three potential speakers
(You may leave this blank if you would like us to provide recommendations):

Name: Title:
Contact Info:    
Name: Title:
Contact Info:    
Name: Title:
Contact Info:    
Audience/Specialty:
Anticipated number of attendees:
Does your institution have established quality improvement measures? Yes No
Not Sure
   

Accreditation Statement
The France Foundation is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Statements
Physicians: The France Foundation designates each live activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Nurses: Nurses who are certified by the American Nurses Credentialing Center (ANCC) may utilize activities that are certified by ACCME-accredited providers toward their requirement for certification renewal by the ANCC. A certificate of attendance will be provided by The France Foundation, an ACCME-accredited provider.