5/4/2016
Live Activity
CME Program Application
Thank you for considering us to support you in your continuing medical
education activity plans. Completing this application is one of the earliest
steps in working with us to achieve your education goals. Should you wish,
you may call us before you begin the application so we can have a
preliminary discussion on your plans. That should make the application
process easier for you. We can be reached at 423 439 8081.
For information that can provide a resource as you complete the application, hover your mouse
over the footnotes both here and throughout this document:
 Application instructions:i
 Deadlines:ii
o Important information related to the months the Board does not meetiii
o Live programs for which Educational Grants are being soughtiv
o Live programs for which brochures must be developedv
 Contact Informationvi
Office Use Only
Activity Type
1. What type of activity are you
proposing?
A live, one-time activity, conference,
symposium, or seminar
Other. Please call us at 423 439 8081
to determine which application you
should be using.
Activity Information
2. Proposed Activity Name:
3. Has this activity been
accredited in the past by the
ETSU Office of CME?
4. Brief description of proposed
1
Additional Planner
Comments
Office Use Only
Additional Planner
Commentsvii
No
Yes. When?
Additional Planner
Commentsviii
Additional Planner
Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016
5/4/2016
activityix
Comments
5. Proposed Date:
Additional Planner
Comments
6. Activity proposed beginning
and ending time:
Additional Planner
Comments
7. Proposed number of
education hours for the
activity:
Additional Planner
Commentsx
8. Location: (city and facility)
Facility:
City:
9. This activity is being planned
by:
An Academic Medical
College/Department
A hospital/healthcare network or it’s
affiliated Medical Staff Organization
Other: Please describe
10. What is the name of the
sponsoring college,
department or organization?
(Please note: no education
will be approved that
imparts only knowledge. All
educational activities must
also address either
competency or
performance.)
13. What data do you have that
2
Additional Planner
Comments
Additional Planner
Comments
Documenting the Need
11. What leads you to believe
this education is needed?
12. Why do you believe your
learners need this
education?
Additional Planner
Comments
Learners need additional knowledge
(A Knowledge need)
They have the knowledge, but need
additional tools, processes or skills to
act on that knowledge (A Competency
need)
They have the knowledge and skills,
but need support in performing at a
consistent level (A Performance need)
Requests by participants in previous
Office Use Only
Additional Planner
Commentsxi
Additional Planner
Commentsxii
Planner Note: For
PARS DATA, this
activity is
considered
A Competency
Activity
A Performance
Activity
A Patient
Outcome
Activity
Additional Planner
Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016
5/4/2016
supports this need? xiii
education activities
Organizational mandate or new
initiative
Emerging clinical guidelines or new
technology
Focused discussion with the physicians
who would potentially attend the
seminar
Quality improvement or performance
data
Primary research on physicians in the
targeted communities
Other. Please explain:
14. All continuing medical
education must contribute
to physician competency.
The following is a list of
ABMS/ACGME Physician
Competencies. Please check
those that would be
addressed in this activity.
Patient carexv
Practice-based learning and
improvementxvi
Interpersonal and communication
skillsxvii
Professionalismxviii
Medical knowledgexix
Systems-based practicexx
15. What barriers to learning do
you believe might exist in
your target audience?xxi
16. How will you design your
activity to help break down
those barriers?
Additional Planner
Comments
Additional Planner
Commentsxxii
Program Format
17. Please describe the program
format for the activity (check
any that apply)
3
Commentxiv
Case-based presentations
Lecture
Panel discussion
Simulation
Skills-based training
Small group discussion
Other. Please describe:
Office Use Only
Additional Planner
Comments
Planner Note: For
PARS DATA, this
conference is
categorized as
Case-based
presentations
Lecture
Panel
discussion
Simulation
Skills-based
Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016
5/4/2016
training
Small group
discussion
Other. Please
describe:
Learning Objectives
18. What will you look for (in
learner competency,
performance or patient
outcomes) that will indicate
this activity has been
successful?xxiii
19. How and when will you
measure this expected
outcome?
20. Please translate these desired
outcomes into 2-5 learning
objectives for the activity:
Office Use Only
Additional Planner
Commentsxxiv
Additional Planner
Commentsxxv
As a result of participating in this activity,
the attendee should be able to…….
1.
Additional Planner
Commentsxxxii
(For assistance in crafting
your objectives, hover you
mouse over a footnote
number to view examples of
verbs that convey
“Knowledge”xxvi ,
“Comprehension”xxvii,
“Analysis”xxviii, “Ability to
Evaluate”xxix, “Application”xxx
“Skill demonstration”xxxi)
Target Audience
Office Use Only
21. Who is your intended
physician audience?
Family Medicine Physicians
Internal Medicine Physicians
OB/GYN Physicians
Pediatricians
Psychiatrists
Surgeons
Emergency Medicine
Other Specialists – Please List:
Additional Planner
Comments
22. Who is your intended nonphysician audience?
Advanced Practice Nurses
Physician Assistants
Pharmacists
Additional Planner
Comments
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Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016
5/4/2016
Psychologists
Nurses
Medical or Nursing Students
Other Specialists – Please List:
23. From what college,
department, community,
region, or organization do
you expect your attendees to
come?
28. Target Audience Size
ETSU
NE TN Region
Knoxville Region
SW VA Region
State of Tennessee
National
An Organization’s Medical Staff –
Please list:
Other– Please List:
Physicians :
NP/PAs:
Non Physicians:
residents)
(excluding residents)
Additional Planner
Comments
(including
Commercial Financial Support
24. Do you intend to seek
commercial support for this
activity?
Additional Planner
Comments
Yes
No
Office Use Only
Additional Planner
Commentsxxxiii
Additional Planner
Comment for PARS
Data
Anticipating:
Grants
Exhibits
Activity Director Information
25. Name of Activity
Directorxxxiv
26. Title
27. Specialty
28. Organization Name / College /
Department
29. Address
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Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016
5/4/2016
30. E-mail Address
31. Phone
32. Fax
Planning Committeexxxv
Name and Title
Specialty
Phone Number
E-mail Address
Contact Information
Contact Person Name
Title
Organization
Address
Phone Number
Fax Number
E-Mail
Is this the person who is
responsible for the day to day
support of this activity?
Yes
No. If no, please detail below:
Responsible individual’s name
Department
Position
Phone number
Fax number
Email address
(more)
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Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016
5/4/2016
Next Steps
You may call the Office of Continuing Medical Education during business hours to receive assistance with
completing this application, or to discuss anything related to your potential activity. Our number is 423-4398081.
Save this as a Word document, and email it to nolandm1@etsu.edu. Within a few days one of our educational
planners will give you a call. BECAUSE WE WILL BE ADDING ADDITIONAL COMMENTS TO THE DOCUMENT,
WE MUST RECEIVE IT IN ITS ELECTRONIC FORMAT.
Submit Required Attachments
Below is the list of additional required attachments. Your application cannot be processed without the
following. All required attachments can be sent electronically or faxed. Our fax number is 423 439 8040.
Our application e-mail address is nolandm1@etsu.edu.
Action
Activity
Director
Provide CV
or Resume
Required
Complete
Conflict of
Interest
Disclosure
Required
Sign
Required
Signatures
Form
Signature
Required
Contact
Person
All Planning
Academic
Committee Department
Members
Chair or
Healthcare
Executive
Instructions
Required
only if
he/she
participates
on Planning
Committee
Required
only if
he/she
participates
on Planning
Committee.
Required
Not required
Please see instructions below to include
your CV
Required
Not required
Go to this link to complete. Please copy
and send this link to all that need to
complete a conflict of interest. Please
note, you must have your CV ready to
attach to your conflict of interest
disclosure
Not
Required
Not Required
Sign Required
Signatures
Form
Required Signature Form can be obtained
at this link: It can be copied and given to
the Activity Director and the
Chair/Healthcare Executive for
signatures. They do not both need to
sign the SAME form. We will accept
either electronic or faxed copies.
- End of Document -
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Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016
5/4/2016
Footnotes
i
Instructions:

This application is in MS Word, and is a form. To complete, put your cursor in a grey shadowed area and start typing. It is
difficult to spell check in a Word Form, so be aware that this is not a problem to us if your spelling is not perfect. If you are the
person completing this application, it is important that you have significant information on the need, focus and expected
outcomes of the proposed activity.

If this is the first time you have completed one of our applications, we do not expect you to complete this application flawlessly.
Once we have received it, our planners will assist you in further refining your application until it is ready for the Advisory Board’s
review. This consultation process is what makes it necessary for the application to be submitted according to the deadlines.

You may contact us at any time if you need clarification on the application or the process.

Once the application is complete, you may either e-mail it to cmeadean@etsu.edu or call the Office of Continuing Medical
Education at (423)439-8081. The contact information is listed at the end of the application.
ii
Deadlines:
All applications and their supporting documentation receive a thorough internal review before they are submitted to the
Advisory Board. Deadlines are set to accommodate that internal review, and to provide the best opportunity for the activity to
be approved.

Advisory Board meetings are the first week of the month. Applications for live conferences must be received by the 10th day of
the month preceding the next Advisory Board meeting. For example, an application that is going to be reviewed by the board
the first week of May must be submitted to the Office of Continuing Medical Education by April 10.

iii
The Advisory Board does not meet in December or July. Applications which would ordinarily be submitted for December or July
review, will need to be reviewed at the November or June meetings respectively.
iv
Add an additional 90 days of planning time to the above application deadlines if your organization would like assistance in securing
educational grants to support the program. PLEASE NOTE THAT NO COMMERCIAL SUPPORT CAN BE REQUESTED OR RECEIVED BY
ANY PARTY TO THE ACTIVITY EXCEPT THE OFFICE OF CONTINUING MEDICAL EDUCATION FOR ANY PROGRAMS ACCREDITED BY THE
OFFICE OF CME AT ETSU.
v
If the applicant would like a brochure developed for the program, add 60 days to the application deadline, to assure that adequate
planning is underway to have the speaker information available for brochure development. WHILE A BROCHURE OR “SAVE THE
DATE” CARD COULD BE MAILED PRIOR TO RECEIVING APPLICATION APPROVAL, NO STATEMENT OF ANY KIND CAN BE INCLUDED
RELATED TO CME CREDIT PENDING OR AVAILABLE.
vi
Office of Continuing Medical Education
James H. Quillen College of Medicine
East Tennessee State University
Box 70572
Johnson City, TN 37614-1708
Phone: 423-439-8081
Fax: 423-439-8040
Email: dnolandm1@etsu.edu.
Website: www.etsu.edu/cme
vii
Planner Notes: If this is a Joint Providership, please add the entity name to the front of the program name.
viii
Planner Notes: Please notate the program number from when it was previously held
ix
EXAMPLE A one day conference for pediatricians and family medicine physicians on the developmental problems most frequently
encountered in children under the age of 20 in Appalachia.
x
Planner Notes: Please adjust hours if needed and attach documentation, if available
xi
Planner Notes: Please translate the need into the “Learning Gap”
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Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016
5/4/2016
Planner Notes: Please accept or modify as appropriate, assuring the need matches the format and objectives. Also
notate if the activity as envisioned by the applicant is designed to address competency or performance, and not impart
only knowledge.
xii
xiii
Examples of data that demonstrates need:
Continuous quality improvement data;
Accreditation site visit reports;
Accreditation requirements;
Health policy studies;
Incident reports/Sentinel events;
Patient records and databases;
Professional review organization studies;
Government reports on health statistics, technology developments, etc.;
Practice audits and reviews;
Recent research articles describing the need;
New techniques, protocols, clinical pathways or guidelines;
Organizational policy or board mandates;
Consensus reports from workshops and committees;
Primary research;
Published expert opinions;
Outcomes of physician surveys;
Evaluation summaries from previous CME activities;
Written faculty perceptions and recommendations;
Committee notes;
Focus groups;
Informal discussions with peers;
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xivPlanner
Notes: Please comment if the data is adequate as is or if you are supplying additional data (and attach or
note the citation where it can be accessed)
xv
Patient care that is compassionate, appropriate, and effective for the treatment of health.
xvi
Practice-based learning and improvement requires investigation and evaluation of their own patient care, appraisal and
assimilation of scientific evidence, and documented improvements in patient care.
xvii
Interpersonal and communication skill results in effective information exchange and team interaction with patients, their families,
and other health professionals.
xviii
Professionalism is manifest by a commitment to carryout professional responsibilities, adherence to ethical principles, and
sensitivity to a diverse patient population.
xix
Medical knowledge demonstrates established and evolving biomedical, clinical and cognate (e.g., epidemiological and socialbehavioral) sciences and the application of this knowledge to patient care.
xx
System-based practice is manifest by actions that demonstrate an awareness of and responsiveness to the larger context and
system for health care and the ability to effectively call on system resources to provide care that is of optimal value.
xxi
Examples of barriers to learning might include such issues as beliefs and attitudes, technology, schedules, organizational dynamics
xxii
Planner Notes: Please comment on whether or not the barriers have been adequately addressed
xxiii
An example would be an observed improvement in the type and timing of diagnostic testing on potential stroke patients after
physician education on the new evidence based guidelines on Acute Stroke.
xxiv
Planner Notes: Please accept or modify as appropriate
xxv
Planner Notes: Please accept or modify as appropriate
9
Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016
5/4/2016
xxvi
Verbs that inform: Cite, Define, Describe, Identify, List, Name, Recite, Record, Recognize, Select, State, Summarize, Update, Write
xxvii
Verbs that denote comprehension: assess, associate, classify, compare, contrast, demonstrate, describe, differentiate, distinguish,
estimate, explain, locate, identify, interpret, predict, report, review
xxviii
Verbs that indicate analysis: analyze, appraise, contrast, criticize, detect, differentiate, distinguish, evaluate, infer, measure,
question, summarize
xxix
Verbs used to evaluate: assess, choose, compare, critique, decide, determine, estimate, evaluate, measure, rate, recommend,
select
xxx
Verbs that demonstrate application: apply, calculate, choose, demonstrate, develop, examine, illustrate, interpret, locate, operate,
practice, predict, report, review, select, treat, use, utilize
xxxi
Verbs that demonstrate skills: demonstrate, diagnose, integrate, manage, measure, operate, perform, record
xxxii
Planner Notes: Please refine and format as required
xxxiii
Planner Notes: If commercial support will be sought, please define what kind of support
xxxiv
The Activity Director must be a physician or nurse practitioner. The Activity Director must have direct involvement in the planning
of the activity, and will need to be in a position to collaborate with the Office of Continuing Medical Education as the planning
unfolds.
xxxv
EXAMPLES: Multidisciplinary (Team) Conference in Geriatrics, e.g.:

Activity Director – Physician (Geriatrician)

Community Physician with interest in geriatrics

Clinical Pharmacist

APN with interest/specialty in geriatrics

Physical Therapist with interest/specialty in geriatrics

Clinical Social Worker or Representative from long-term care facility
EXAMPLES: Pediatric Specialty Conference, e.g.:

Activity Director – Physician (Pediatrician with interest in topic)

Family Medicine Physician

Pediatric Resident/Fellow

FNP Representative from practice site
 Public Health Representative
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Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016