School of Pharmacy
Continuing Pharmacy Education
Faculty/Speaker Application for Home Study CPE Activities
Read the Faculty Guidance Document when completing this application. This form MUST BE
SUBMITTED ELECTRONICALLY AT LEAST 40 DAYS PRIOR TO THE ACTIVITY DATE.
E-mail all documents with the exception of the signed Conflict of Interest Declaration which
must be faxed or mailed (unless an electronic signature is used) to wsigang@siue.edu
.
Author(s): Submit a current CV with this application.
Faculty/Author Name(s):
(Include degrees and other credentials, i.e. R.Ph., Pharm.D., BCPS, etc.)
Institution/Employer:
Mailing Address:
E-mail Address:
Daytime Telephone:
Proposed Activity length (hr. or CEU):
Proposed CE Activity Availability:
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Activity Subject Matter
What is the Title of this Activity?
Provide 3-4 key words for this presentation (i.e. drug dosing, law, cardiology etc.) and the names
of any drugs that are the focus of the activity.
Who is the target audience for this activity? (pharmacists, techs, institutional pharmacists etc.).
____________________________________________________________________________
This activity is part of a larger conference or event.
What type of activity will this be? All activities must be based on evidence as accepted in the
literature by the health care professions.
Knowledge: transmit knowledge, recall of facts
Application: apply information learned
Check off the designator codes related to your activity. At least one is required.
Disease State/Clinical
AIDS Therapy
General Pharmacy
Patient Safety
Law Related to Pharmacy
How do you plan to announce this activity? Check all that apply. Final activity announcements
must be approved by the continuing education office prior to dissemination.
Internal Email
External Email
Posters
Save the Date Postcard
Web Site (please specify)
Other
If you have a promotional brochure for this activity, attach it with this submission.
There will be a registration fee for this activity.
CPE Activity Planning Form
1. All CPE activities must be for scientific and educational purposes only.
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2. The Office of CPE must be involved in the planning, implementation and evaluation of
any CPE activity for which it chooses to enter a joint sponsorship with a non-accredited
entity.
3. The Office of CPE must review and approve the needs assessment process, supporting
learning objectives, design of the educational activity, final faculty selection and
educational methodology.
4. The Office of CPE must review and approve all materials associated with the activity
prior to their release (including any marketing materials).
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Activity Planning Form
Directions: List suggested educational objectives to support the identified need (as outlined in the faculty guidance). The objectives
must be an EXACT match to all materials that will be used in promotional and program materials.
Activity Title:
Universal Activity Number (office of CPE only):
Learning Objectives
(A)
What instructional
materials will be utilized to
meet this objective? (i.e.
outlines, slides, case studies,
computer-assisted
techniques, etc.)
Example: Explain the differences between NPH and
regular insulin
Table listing the
pharmacokinetic properties of
the insulin agents
(B)
What active learning methods
will be utilized to meet this
objective?
Please indicate those
methodologies that fostered
active participation in learning
(i.e. group-based learning,
workshops, demonstrations,
etc.)
Two patient case study
presentations
(C)
What learning assessment activities will
be utilized to enable participants to
assess their achievement?
(i.e. case studies, problem solving activities,
post-tests, multiple choice questions,
hands-on demonstration, etc.)
First case will be assessed by participant
individual and then group discussion.
Second case will be presented as the posttest with multiple choice responses.
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2.
3.
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5.
Return to: Walter Siganga, RPh. PhD. Director, Continuing Pharmacy Education  Southern Illinois University Edwardsville School of Pharmacy  200 University
Park Drive, Box 2000  Edwardsville, IL  62026-2000  618-650-5135 phone  618-650-5152 fax  wsigang@siue.edu
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Needs Assessment
What methods were used to determine the educational needs of the target audience? Please
check all that are applicable.
Public Health Data
Survey of Targeted Audience
Industry Sources
Previous Activity Evaluation Data
Literature Search
New Developments/Techniques
Other _____________________________________________________
State the practice gap that you have identified to justify your reason for developing this activity.
State the overall need/educational goal for the activity. Include linkage of identified need to
learning objectives.
Program Evaluation
This activity is designed to change the performance of practitioners who complete it.
If yes, describe your plan to measure the change in practitioner competence.
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This activity is designed to change patient health outcomes.
If yes, describe your plan to measure the change in patient outcomes.
This activity is designed to change population health.
If yes, describe your plan to measure the change in population health.
Disclosure Statement for CPE Faculty/Authors/ Planning Committee Members
It is the policy of the SIUE Office of CPE to insure balance, independence, objectivity, and
scientific rigor in all its sponsored educational activities. Disclosure must be made to the
audience of any real or apparent conflict(s) of interest that may have a direct bearing on the
subject matter of the continuing education activity.
This pertains to relationships with pharmaceutical companies, biomedical device manufacturers,
or other corporations whose products or services are related to the subject matter of the
presentation topic.
The intent of this policy is not to prevent a speaker with a potential conflict of interest from
making a presentation. It is intended that any potential conflict should be identified openly so
that the participants may form their own judgments about the presentation with the full
disclosure of the facts. It remains for the audience to determine whether the speaker's outside
interests may reflect a possible bias in the exposition of the conclusions presented.
o Commercial interest is defined as any proprietary entity producing health care goods or
services, with the exception of non-profit or government organizations and non-health
care related companies.
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Conflict of Interest Declaration
The Office of Continuing Pharmacy Education requires that all involved in controlling content in a CPE activity must disclose any relevant
commercial of interest. This form must be returned at the beginning of the planning process. There must also be disclosure of all
commercial interests to participants prior to the activity.
Activity Title: _______________________________________________________________________
Faculty Name/Title: __________________________________________________________________
□ Planner
□ Speaker/Faculty □ Content Specialist
□ Moderator
PART 1: TO BE COMPLETED BY PARTICIPANT (read ACPE guidelines on non-commercialism)
□ I or my spouse/partner have no actual or potential conflict of interest in relation to this activity.
□ I or my spouse/partner have a financial interest/arrangement, affiliation or relationship with one or more
organizations that could be perceived as a real or apparent conflict of interest in the context of
the subject of this activity, including but not limited to:
Self
Spouse/Partner
Consultant/Clinical investigator: _________________________________________
Grant/research support: _______________________________________________
Stockholder: ________________________________________________________
Speaker's Bureau/governing board: ______________________________________
Other financial/material interest: _________________________________________
I understand the above information will be disclosed to the audience in advance of the activity verbally (for live activities) and in
print. My disclosure provided above is accurate for the past 12 months. All recommendations involving clinical medicine in my
presentation are based on evidence that is accepted within the health profession as adequate justification for their indications
and contraindications in the care of patients. All scientific research referred in, reported, or used in support or justification of a
patient care recommendation must conform to the generally accepted standards of experimental design, data collection, and
analysis.
I understand that I must submit activity materials (i.e. slides, handout, home study activities) at least 3 weeks in advance of the
event so that they may be reviewed for conflict of interest/potential bias.
______________________________________
Signature
____________________
Date
I confirm that my typed name serves as my electronic signature.______ yes
_____ no
PART 2. TO BE COMPLETED BY CPE DIRECTOR
If conflict of interest are present, the conflicts were resolved by the following process (check one):
□ Peer review
□ Individual ended relationship
□ Selected an alternative person
□ Other_______________________________________________ Accepted by/date __________________
PLEASE FAX THE COMPLETED FORM TO:
Walter Siganga, RPh., PhD. Director of Continuing Pharmacy Education. SIUE School of Pharmacy, 200 University
Park Drive, Box 2000, Edwardsville, IL 62026-2000. Tel. (618) 650-5135 Fax (618) 650-5152 wsigang@siue.edu
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