5/4/2016
Live Course/Class
CME Program Application
Quillen College of Medicine, East Tennessee State University, Office of Continuing Medical Education
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 meet iii
o Course/class for which Educational Grants are being soughtiv
 Contact Informationv
Activity Type
1. Type of Course/Class
A course/class which may be offered
once or more times during the year.
Each time the course/class is offered
participants change, but not the
content. Example: ACLS,
Fundamentals of Critical Care
Other, please describe.
Course/Class Information
2. Proposed
Course/Class Name:
3. Has this activity been
accredited in the past by
the ETSU Office of CME?
1
Additional Planner
Comments
Office Use Only
Additional Planner
Commentsvi
No
Yes. When?
4. Brief description of
proposed course/class
5. Is this a class (in which
the content is offered
during multiple
sessions) or is it
Office Use Only
Additional Planner
Commentsvii
Additional Planner
Comments
Class
How many sessions are there in
one class?
How many hours of contact are
Additional Planner
Comments
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 5/4/2016
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course (in which all
the content is offered
in one session)?
Note: Please attach a
schedule for the
course/class for the
application year,
including number of
times it is offered,
proposed dates, and start
and end times
6. Location: (city and
facility)
7. When do you expect
this course/class to
first be held?
8. This course/class is
being planned by:
there in each session?
How many hours of contact are
there in the entire class?
Course
How many times in the next year
to you anticipate this course
being offered?
How many hours of contact in the
course?
Additional Planner
Comments
Additional Planner
Commentsviii
Medical school/department
A hospital/healthcare network or its
affiliated medical staff organization
Other: Please describe
Documenting the Need
9. What leads you to
believe this education
is needed?
10. What data do you
have that supports
this need?
11. Why do you believe
your learners need
this education?
2
Additional Planner
Comments
Office Use Only
Additional Planner
Commentsix
Quality improvement or
performance data
Potential participant’s request
Organizational mandate or new
initiative
Emerging clinical guidelines or new
technology
ABMS/ACGME competencies that
need to be addressed
Other. Please explain:
Additional Planner
Commentsx
Learners need additional knowledge Additional Planner
(A Knowledge need)
Commentsxi
They have the knowledge, but need
additional tools, processes or skills to Planner Note: For PARS
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 5/4/2016
5/4/2016
(Please note: no
education will be
approved that imparts
only knowledge. All
educational activities
must also address
either competency or
performance.)
12. What barriers to
learning do you
believe might exist in
your potential
learners?xii
13. How will you design
your activity to help
break down those
barriers?
14. All Continuing Medical
Education is required
to contribute to
physician competency.
The following is a list
of ABMS/ACGME
Physician
Competencies. Please
check those that
would be addressed in
this series.
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)
Additional Planner
Commentsxiii
Patient carexiv
Practice-based learning and
improvementxv
Interpersonal and communication
skillsxvi
Professionalismxvii
Medical knowledgexviii
Systems-based practicexix
Course/Class Format
15. Is this Course/Class
being offered in
conjunction with a
third party who
stipulates the content,
instructor
requirements, format,
and stipulates the
mode and/or content
of testing?
3
DATA, this activity is
considered
A Competency
Activity
A Performance
Activity
A Patient Outcome
Activity
Additional Planner
Comments
No, we are developing the content
and choosing the instructor(s)
Yes, the course/class specifics are
stipulated by a third party
Who is that third party?
What do they stipulate?
Content
Format
Schedule
Instructor qualifications
Testing process and
execution
Hand out materials
Testing forms
Sign in Sheets
Additional Planner
Comments
Office Use Only
Additional Planner
Comments
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 5/4/2016
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Evaluations forms
16. What format will be
used to support the
learning?xx
Planner Note: For PARS DATA, this
conference is categorized as
Case-based presentations
Lecture
Panel discussion
Simulation
Skills-based training
Small group discussion
Other. Please describe:
Learning Objectives
17. What will you look for
(either in clinical
practice or patient
outcomes) that would
indicate this
course/class has been
successful?
18. How and when would
you measure that
outcome?
19. Please translate these
desired outcomes into
2-3 learning objectives
for the course/class:
(For assistance in
crafting your
objectives, hover you
mouse over a footnote
number to view
examples of verbs that
convey “Knowledge”xxi
, “Comprehension”xxii,
“Analysis”xxiii, “Ability
to Evaluate”xxiv,
“Application”xxv “Skill
4
Additional Planner
Comments
Planner Note: For PARS
DATA, this conference is
categorized as
Case-based
presentations
Lecture
Panel discussion
Simulation
Skills-based training
Small group
discussion
Other. Please
describe:
Office Use Only
Additional Planner
Comments
Additional Planner
Comments
As a result of participating in this
course/class, the attendee will be able
to…….
1
2
3
Additional Planner
Comments
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 5/4/2016
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demonstration”xxvi)
Target Audience
20. Who is your intended
physician audience?
Internal Medicine Physicians
Family Medicine Physicians
OB/GYN Physicians
Surgeons
Pediatricians
Psychiatrists
Emergency Medicine Physicians
Pathologists
Other Specialists – Please List:
21. Who is your intended
non-physician
audience?
Advanced Practice Nurses
Physician Assistants
Pharmacists
Psychologists
Nurses
Medical or Nursing Students
Other Specialists – Please List:
22. From what
department,
community, region, or
organization do you
expect your attendees
to come?
ETSU
28. Target Audience Size
per course/class
College of Medicine
Department:
Health Science College:
Tri-Cities
NE TN Region
Knoxville Region
SW VA Region
State of Tennessee
National
An Organization’s Medical Staff –
Please list:
Other– Please List:
Physicians (excluding residents)
Physician Residents
APNS/PAs
Other Non-Physicians
Commercial Financial Support
23. Do you intend to seek
commercial support
for this activity? xxvii
5
Yes
No
Office Use Only
Additional Planner
Comments
Additional Planner
Comments
Additional Planner
Comments
Office Use Only
Additional Planner
Commentsxxviii
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 5/4/2016
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Additional Planner
Comment for PARS Data
Anticipating:
Grants
Exhibits
Activity Director Information
24. Activity Director
namexxix
25. Title
26. Specialty
27. Organization Name /
College / Department
28. Address
29. E-mail Address
30. Phone
31. Fax
Planning Committeexxx
Name and Title
Specialty
Phone Number
E-mail Address
Contact Information
Contact Person Name
Title
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 5/4/2016
5/4/2016
Organization
Address
Phone Number
Fax Number
E-Mail
Is this the person who is
responsible for the day to
day support of this
course/class?
Yes
No. If no, please detail below:
Responsible individual’s name
Department
Position
Phone number
Fax number
Email address
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.
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 5/4/2016
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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
Required
only if
he/she
participates
on Planning
Committee
Required
only if
he/she
participates
on Planning
Committee.
Not
Required
All Planning
Committee
Members
Academic
Department
Chair or
Healthcare
Executive
Instructions
Required
Not required
Must be submitted electronically at the
same time as the completed Conflict of
Interest Disclosure (see below).
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.
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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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 5/4/2016
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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
Commercial support is rarely sought for Course/class. Please discuss this with your CME Planner, and be aware that
NO commercial support can be requested or received by any party to the course/class except by the Office of Continuing
Medical Education.
v
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: nolandm1@etsu.edu.
Website: http://www.etsu.edu/com/cme/
vi
Planner Notes: If this is a Joint Providership, please add the entity name to the front of the program name.
Planner Notes: Please notate the program number from when it was previously held. Please also notate the number
of time the program met last year/the number of times it was approved to meet.
vii
Please notate if this activity begins the day of the board meeting, the beginning of the next calendar month, or
the date of the first activity.
viii
ix
Planner Notes: Please translate the need into the “Learning Gap”
Planner 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)
x
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.
xi
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xii
Examples of barriers to learning might include such issues as beliefs and attitudes, technology, schedules, organizational dynamics
xiii
Planner Notes: Please comment on whether or not the barriers have been adequately addressed
xiv
Patient care that is compassionate, appropriate, and effective for the treatment of health.
xv
Practice-based learning and improvement involves investigation and evaluation of their own patient care, appraisal
and assimilation of scientific evidence, and improvement in patient care.
xvi
Interpersonal and communication skill results in effective information exchange and teaming with patients, their
families, and other health professionals.
xvii
Professionalism is manifest by commitment to carryout professional responsibilities, adherence to ethical principles,
and sensitivity to a diverse patient population.
xviii
Medical knowledge demonstrates established and evolving biomedical, clinical and cognate (e.g., epidemiological
and social-behavioral) sciences and the application of this knowledge to patient care.
xix
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.
xx
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
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
Examples of Educational Format:
Case presentations;
Clinical skills assessments;
Computer assisted learning;
Lecture; Hands on skills lab;
Panel discussion; Self assessment;
Simulation or standardized patients;
Teleconferencing;
Video or audio presentations;
Workshops;
Other.
xxi
Verbs that inform: Cite, Define, Describe, Identify, List, Name, Recite, Record, Recognize, Select, State, Summarize,
Update, Write
xxii
Verbs that denote comprehension: assess associate, classify, compare, contrast, demonstrate, describe, differentiate,
distinguish, estimate, explain, locate, identify, interpret, predict, report, review
xxiii
Verbs that indicate analysis: analyze, appraise, contrast, criticize, detect, differentiate, distinguish, evaluate, infer,
measure, question, summarize
xxiv
Verbs used to evaluate: assess, choose, compare, critique, decide, determine, estimate, evaluate, measure, rate,
recommend, select
xxv
Verbs that demonstrate application: apply, calculate, choose, demonstrate, develop, examine, illustrate, interpret,
locate, operate, practice, predict, report, review, select, treat, use, utilize
xxvi
Verbs that demonstrate skills: demonstrate, diagnose, integrate, manage, measure, operate, perform, record
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xxvii
Commercial support is rarely sought for Regularly Scheduled Series. Please discuss this with your CME Planner, and
be aware that NO commercial support can be requested or received by any party to the series except by the Office of
Continuing Medical Education.
xxviii
Planner Notes: If commercial support will be sought, please define what kind of support
xxix
The Activity Director must be a physician or nurse practitioner. The Activity Director must have direct involvement in
the planning of the course/class, and will need to be in a position to collaborate with the Office of Continuing Medical
Education as the planning unfolds.
xxx
EXAMPLE: Specialty Speaker (same curriculum, various locations), e.g.:
 Activity Director (Physician speaker)
 Primary Care Physician (representing target audience)
 Rural Physician (representing target audience)
(Committee must have contact with a representative from each site/location that speaker intends to present at, to
determine needs of target audience at that site.)
EXAMPLE: Quality Improvement Course, e.g.:
 Activity Director – Physician who sits on QI or Peer Review Committee of that institution.
 Physician(s) from medical staff
 QI Representative (from institution(s))
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 5/4/2016