September 2017 - June 2018

Form Approved
OMB Number 0925-0698
Exp. Date 5/31/2017

Remote Site Request Form


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In order to become a registered remote site, you must meet the following requirements:

  • Your site must be affiliated with one of the following: a university, hospital, healthcare facility, learning institution, academic medical center, or a research center.
  • Have at least 3 participants who register for the course and take the final examination.
  • Have a remote site Chairperson and Liaison (which can be the same person).
  • The Chairperson must hold an advanced degree (MD, PhD, DO, DDS, NP, MPH, etc...).

Please fill in the following information:

(Use upper & lower case characters and please do not use abbreviations)

Name of Remote Site Chairperson

Name of Remote Site Liaison

Role of Remote Site Chairperson

  • Engage their institutional participants in discussion regarding the course content
  • Help convey the lecture information to practical applications for their participants
  • Encourage their participants to take the exam and get their certificates of completion (sites will be reviewed for examination rates on an annual basis).

Role of Remote Site Liaison

  • Advertise the course at their site and encourage their members to register for the course.
  • Send weekly reminders to their site's participants encouraging them to view at least one lecture per week.
  • Encourage their participants to take the examination and obtain their certificates of completion.

Once you submit this online Remote Site Request Form, it will then be reviewed by the IPPCR program coordinator and the course co-Directors. You will receive a message within one to two business weeks of your submission informing you if your request to set up a remote site has been approved or not approved.