Faculté de médecine | Faculty of Medecine
Bureau de Dévelopement professionnelle continue / Office of Continuing Professional
Development
Application for CPD Accreditation
Office of Continuing Professional Development
University of Ottawa, Faculty of Medicine
Loeb Research Building, 725 Parkdale Ave, Office 158
Ottawa, ON K1Y 4E5
Tel.: 613-798-5555 ext 16646 / Fax: 613-761-5262
Email: CMEaccreditation@toh.on.ca
Website http://www.med.uottawa.ca/cme/eng/accreditation.html
Program Title:
Types and number* of Credits applied for:
☐ Section 1 _____ Credits
☐ Mainpro-M1 _____ Credits
*Number of credits requested is based on the number of hours of learning activity, excluding breaks
and lunches.
Program Date(s):
If this is a recurring program within the next 12 months, will its organization, delivery and content
remain unchanged? ☐ Yes
☐ No
If yes, how many times will it be held?
☐1 ☐ 2 ☐3 ☐ 4 ☐More
Location(s):
Date(s) of program:
1. The physician organization or medical organization
Name:
Telephone:
Email:
Fax
2. Primary (accountable) physician planner requesting approval:
Name:
Telephone:
Fax:
Email:
This question for Mainpro 1 applications only:
3. The family physician, a member of the CFPC:
And please complete the “Statement of Involvement Form”, included at the end of this
application form.
Name:
4. The educational non-physician co-sponsoring organization:
Name:
Telephone:
Email:
Fax:
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Faculté de médecine | Faculty of Medecine
Bureau de Dévelopement professionnelle continue / Office of Continuing Professional
Development
5. Name of program organizer (if different from above):
Telephone:
Email:
Fax:
6. Name to send assessment to (c/o the chair of the planning committee):
Telephone:
Email:
Fax:
Declaration:
As the physician requesting approval for this activity, I accept the responsibility for the accuracy of the
information provided in response to the questions listed on this application, and to the best of my knowledge, I
certify that the CMA’s guidelines, entitled, CMA Policy: Physicians and the Pharmaceutical Industry, have been
met in preparing for this event.
If this event is held in Québec, we are aware that it is mandatory to adhere to the Conseil de l’ÉMC du
Québec’s Code of Ethics entitled, Code of Ethic for parties involved in Continuing Medical Education.
Signature (or equivalent) of the chair of the planning committee requesting approval:
Physician’s Name (please print)
Physician’s Signature:
Date:
1. The completed accreditation application form along with all of the supporting documentation
may be sent by email (preferred) or regular mail. Please contact us if you wish to send by
regular mail.
Email to: CPDaccreditation@toh.on.ca and rparson@toh.on.ca
Subject: name_of_your_program accreditation application
2. Accreditation Fees
Accreditation fee 2013 schedule (applies to 2014 as well)
Cheques payable to: University of Ottawa, CPD,
Or: Credit Card form for payment of application fee
You can also contact our administrative assistant, Sylvie Stang-Girouard, for any questions regarding
payment:
Sylvie Stang-Girouard
Administrative Assistant/ Adjointe Administrative
Tel: 613-798-5555 ext. /poste 16646
Email: sstang@toh.on.ca
CMEaccreditation@toh.on.ca
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Faculté de médecine | Faculty of Medecine
Bureau de Dévelopement professionnelle continue / Office of Continuing Professional
Development
What to include with your application
Mandatory documents and important information!
Please review before submitting.
A completed copy of this application and supporting documentation is
☐ Application
form
required.
 Send an electronic copy of the documents to the office of CPD:
CPDaccreditation || Formation médicale continue – Agrément
CPDaccreditation@toh.on.ca
Review of application takes 6-8 weeks.
Must be received before the application is reviewed.
☐ Application
fee
Cheques can be made payable to “CPD, University of Ottawa”.
We accept VISA, MasterCard or AMEX. Credit card payment form is available
at http://www.med.uottawa.ca/cme/eng/accreditation.html
This form is to be submitted only by FAX.
Application fees are non-refundable regardless of the outcome of the
review process.
Budget
Disclosing and naming specific:
☐
 funding sources (with or without industry sponsorship)
 any other revenue
 expenditures
Please include the expected number of registrants in the budget
document.
Must include:
☐ Evaluation
form
 a question pertaining to industry bias
 a question on whether the stated learning objectives were met
 an opportunity for participants to reflect on the content of the session
Program brochure for the event must include:
☐ Detailed
Program
 the activity learning objectives
 a list of speakers, topics, start and end times of individual sessions
 the interactive discussion periods (need to be clearly indicated on the
program agenda)
 the sessions for which accreditation is being requested
Please provide
☐ Disclosure
form*
 a copy of the conflict of interest document
 a description of how this information is collected and disclosed to
participants.
*A conflict of interest document is required regardless of how the
course/conference is funded.
Indicate draft or final copy),
☐ Registration
Form
Include invitation letter and/or website link for registration if available.
Note: Applicants should keep a list of attendees for record purposes for a period of 5 years.
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Faculté de médecine | Faculty of Medecine
Bureau de Dévelopement professionnelle continue / Office of Continuing Professional
Development
PART 1: Organization requirements
Activities eligible for approval under Section 1 must meet one of the following requirements.
Indicate which option applies to your organization:
☐
Option 1: We are a physician organization that planned this education event alone or
in conjunction with another physician organization:
☐
Option 2: We are a physician organization that is co-developing this educational
event with a non-physician organization. We (the physician organization) have been
prospectively involved in planning this event and accept accountability for its entire program.
Definition of Physician Organization:
A not-for-profit group of health professionals with a formal governance structure, accountable to and serving, among others,
specialist physicians through continuing professional development, provision of health care; and/or research.
This definition includes (but is not limited to):
▪ faculties of medicine
▪ hospital departments or divisions
▪ medical academies
▪ medical societies
▪ medical associations
▪ health branch of the Canadian forces
Non-physician organization: A disease-oriented organization, pharmaceutical company or advisory group, medical supply or surgical
supply company, communications company or other for-profit organization.
PART 2: Education standards
Criterion 1: The activity must be planned to address the identified needs of the target
audience.
Please provide an explanation or supporting documentation for each of the following questions:
1. Describe the identified target audience for this event.
If applicable, please indicate if this event is also intended to include other health professionals.
2. List all members of the planning committee, including their medical specialties or health
professionals. In the case of the co-development of this educational event, please indicate
which members are representing the physician organization.
Planning committee
Chair(s):
Members
Name, specialization, Tel., Email
Name, specialization, (for each)

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Faculté de médecine | Faculty of Medecine
Bureau de Dévelopement professionnelle continue / Office of Continuing Professional
Development
Description of needs assessment:
What sources of information were selected by the planning committee to determine and develop
the content of this event?
Please check all methods used for determining Objective (unperceived) and Subjective (perceived)
educational needs of the target audience,
At least one objective and one subjective educational need should be used.
1. Perceived (subjective) needs:
These address the gap from the learners’ point of view. What are they looking for? What is most
important to them and their patients?
☐ Questionnaire or survey
☐ Opinion of Planning Committee
☐ Focus groups
☐ Other: please specify:
2. Unperceived (objective) needs:
These needs are the gaps between present and optimal care that a learner does not know exist;
when learners do not know what they do not know.
☐ Self-assessment tests
☐ Chart audits
☐ Chart stimulated recall interviews
☐ Direct observation of practice performance
☐ Quality assurance data from hospitals, regions
☐ Standardized patients
☐ Provincial databases
☐ Incident reports
☐ Published literature (RCT, cohort studies)
☐ Other: please specify:
3. Please provide a brief summary of the needs assessment results.
What gaps in knowledge, attitudes, skills or performance did the planning committee identify
for this event?
Criterion 2: Learning objectives that address identified needs must be created for the overall
event and individual sessions.
The learning objectives must be printed on the program brochure and/or handout materials.
 A copy of your program brochure will suffice if it includes this information.
Or
 Please respond to the following questions:
What learning objectives were developed for:
☐
The overall event?
☐
Specific sessions?
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Faculté de médecine | Faculty of Medecine
Bureau de Dévelopement professionnelle continue / Office of Continuing Professional
Development
Criterion 3: At least 25% of the total education time must be devoted to interactive learning
strategies.
Please include the proposed event schedule, with times indicating question and answer or
discussion periods, workshops, small group sessions, etc.
What learning methods are you using in the activity?
☐ Lectures
☐ Workshops
☐ Case-based Learning
☐ Panel discussions
☐ Small group discussions (less than 16)
☐ Audience response system
☐ Simulation or role plays
☐ Demonstrations of skills or techniques
☐ Question and answer sessions
☐ Other: (please specify) __
Criterion 4: The event must include an evaluation of the event’s established learning
objectives and the learning outcomes identified by participants.
(Check those that apply to your evaluation)
The evaluation strategies for activities approved under Section 1 must include:
☐ An assessment of the achievement of each session’s learning objectives
☐ Opportunities for participants to reflect on and identify what they have learned and its
potential impact for their practice
☐
A question asking about bias
Here are some other possible themes for the evaluations (not required for accreditation)
☐ Overall effectiveness of the event
☐ Teaching abilities of the speaker(s)
☐ Effective use of interaction to explore session or event content
☐ Relevance of course content to the target audience's learning needs
☐ Gaps in knowledge that were addressed
☐ Personal learning projects that the participant wishes to pursue, etc.
1. Please provide a copy of the evaluation form(s) developed for this event, and respond to the
following questions:
2. Does the evaluation strategy intend to measure improved participant performance?
Yes: ☐
No: ☐
If yes, please describe the tools or strategies used.
3. Does the evaluation strategy intend to measure improved healthcare outcomes?
Yes: ☐
No: ☐
If yes, please describe the tools or strategies used.
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Faculté de médecine | Faculty of Medecine
Bureau de Dévelopement professionnelle continue / Office of Continuing Professional
4. Will the participantsDevelopment
receive feedback related to their learning?
Yes: ☐
No: ☐
If yes, please describe the tools or strategies used.
PART 3: Ethical Standards
Group CME/CPD events approved under Section 1 must meet the CMA Guidelines governing the
relationship between physicians and the pharmaceutical industry.
(Please note that these guidelines will have been met if University of Ottawa, CME Commercial Support
Guidelines of CME/CPD activities have been met).
Guidelines are available on our OCPD website or see:
http://www.med.uottawa.ca/cme/assets/documents/FoM_Industry_Relations_Policy_EN.pdf
Note:
Any financial assistance provided by industry (for travel or accommodation) to reimburse
physicians or their families for attending an educational event would result in non-approval of this
application.
For more information on the CMA guidelines regarding financial support from industry, please see the
CMA Policy: Physicians and the Pharmaceutical Industry (Update 2004).
http://www.med.uottawa.ca/cme/assets/documents/accreditation2011_Form/18_CMA_Policy.pdf
Or
http://policybase.cma.ca/dbtw-wpd/Policypdf/PD08-01.pdf
Each of the following ethical standards MUST be met for this event to be approved under Section 1:
1. The physician organization(s) must have control over the topics, content and speakers selected
for this event.
We comply with this standard:
Yes: ☐
No: ☐
Describe the process by which the topics, content and speakers were selected for this event.
2. The physician organization(s) must assume responsibility for ensuring the scientific validity and
objectivity of the content of this event.
We comply with this standard: Yes: ☐
No: ☐
Describe the process to ensure validity and objectivity of the content for this event.
3. The physician organization(s) must disclose to participants all financial affiliations (within the last
two years) of faculty, speakers, moderators or members of the planning committee regarding
information being presented at a CME/CPD event.
We comply with this standard: Yes: ☐
No: ☐
Describe how conflict of interest information is collected and disclosed to participant.
4. All funds received in support of this activity must be provided in the form of an educational grant
payable to the physician organization(s) for management and disbursement.
We comply with this standard: Yes: ☐
No: ☐
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Faculté de médecine | Faculty of Medecine
Bureau de Dévelopement professionnelle continue / Office of Continuing Professional
Development
5. Provide a copy of the budget that identifies each specific:
☐ Source of revenue (including registration fees)
☐ Funding (all sponsors and their contributions, if applicable)
☐ Expenditures
Please describe how the physician organization(s) assumes responsibility for the distribution of
these funds, including the payment of honoraria to faculty.
6. No drug or product advertisements may appear on or with any of the written materials
(preliminary or final programs, brochures, or advance notifications) for this event.
We comply with this standard: Yes ☐
No ☐
Provide a copy of the preliminary program, brochure, or advance notification for this event.
7. Generic names should be used rather than trade names on all presentations and written
materials.
We comply with this standard: Yes ☐
No ☐
Describe the process to advocate speakers’ adherence to using generic rather than trade
names of medications and/or devices included within all presentations or written materials.
We comply with the above 6 standards.
Yes ☐
No ☐
Page 8 of 9
Faculté de médecine | Faculty of Medecine
Bureau de Dévelopement professionnelle continue / Office of Continuing Professional
Development
OFFICE OF CONTINUING PROFESSIONAL DEVELOPMENT
Statement of Involvement in Program Planning
This form must be completed and signed by a CCFP physician who is an active member of the
planning committee that developed or co-developed this activity.
Program Name:
Program Date:
√
Initials
I have had substantial input into this program*
I have reviewed the content to ensure it is relevant to family medicine
I verify that the planning, content and conduct of this program meets pertinent
ethical standards
I have been informed of any financial and/or non-financial incentives associated
with this program
*Substantial input:
The CFPC member must be an active member of the planning committee (and, where it exists, the
program scientific committee)
Actively contribute to the consideration of learning needs, the determination of learning objectives, the
choice of speakers, selection of appropriate venues, etc.
Participate in and/or be privy to all issues and decision related to the CME program budget, including
sponsorship, costs to participants, honorariums etc.
Be a resident of the province (and ideally from the region) where the CME program is to be held
Contact information:
MEMBERSHIP NUMBER (REQUIRED)
NAME:
TEL. (W):
ADDRESS LINE 1:
ADDRESS LINE 2:
CITY:
TEL. (C):
PROV.:
POSTAL CODE:
FAX:
E-MAIL ADDRESS:
______________________________
________________________________
Signature
Date
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