Type of Application
EASTERN VIRGINIA MEDICAL SCHOOL
OFFICE OF CONTINUING MEDICAL EDUCATION
New
Renewal
Date Reviewed:
APPLICATION FOR DESIGNATION OF AMA PRA CATEGORY 1 CREDITTM
ACTIVITY INFORMATION:
Title of Proposed CME Activity:
Location:
Room:
City:
Date(s):
Days: Mon.
CME Sponsor:
Tue.
Wed.
Time:
Thur.
Fri.
Sat.
Sun.
EASTERN VIRGINIA MEDICAL SCHOOL
Direct Sponsor: EVMS Department/Program
Joint Sponsor: Hospital/Organization
Course Director :
Mailing Address:
E-mail:
Phone:
Fax:
Phone:
Fax:
Contact Person:
Mailing Address:
E-mail:
SIGNATURES
I agree to work with the Office of Continuing Medical Education to ensure that all the required educational, accreditation and
logistical elements are consistent with the policies and procedures of the ACCME and Eastern Virginia Medical School.
Course Director
Date
Department Chair (direct) or Organizational Representative (joint)
Date
CME Office
Date
CME USE ONLY
Program Identification Number:
Petitioning for
Certification Period:
AMA PRA Category 1 Credit(s)™
Approved_______Not Approved
Reason Denied
________________________________________________________
CME Committee Chairman (signature)
____________________________
Date
Revised:February 2011
1
ESSENTIAL AREA 2: EDUCATIONAL PLANNING AND EVALUATION
A.
PURPOSE
1.
State the reason for planning this activity. What is the professional practice gap? In other words, what
is the problem being addressed? What is the difference between actual and ideal performance or patient
outcomes?
.
2.
Now that the problem or gap is identified, determine the learning need. What is causing this gap?
What do physicians need to learn or do differently to close this gap?
2.
Which of the following educational needs for the learner will this activity address?
Physician knowledge
Physician competence
Physician performance
Patient outcomes
B.
EDUCATIONAL NEED
NEEDS ASSESSMENT DATA
C.
Expert Needs
Participant Needs
Observed Needs
Environmental
Scanning
Planning Committee
Department Needs
Activity Faculty
Expert Panels
Peer Reviewed
literature
New medical
information
Research Findings
Certification
requirement
Licensure
requirement
Previous course
evaluation
Focus panel
discussions
Needs assessment
survey
Requests from
physicians
Requests from
affiliated institutions
Hospital/medical school
quality assurance analysis
Clinical observations
Practice Referral data
Mortality/Morbidity data
Epidemiological data
National clinical guidelines
(NIH, NCI, AHRQ, etc)
Specialty society guidelines
Database analysis (e.g., Rx
changes, diagnosis trend)
Lay press
Direct-to-consumer
advertising
Other societal trends
Other Identified Needs
________
PLANNING
Planning Committee: List the physicians and other individuals responsible for planning this activity:
Were disclosure forms signed by planning committee?
Were all conflicts of interest resolved prior to the activity?
Yes
Yes
No
No
Revised:February 2011
2
D.
TARGET AUDIENCE
1. Primary Audience:
2. Geographical target area:
3. Estimated number of attendees:
FT faculty
E.
Community Physicians
Residents
Medical Students
Other healthcare
COURSE DESIGN
1.
OBJECTIVES: Based on the desired results, state the objectives relative to physician knowledge, competence
(knowing how to), performance (practice behavior) and/or patient outcome.
2. CONTENT*: Based on the physician target audience and the identified professional gap, describe the content
that should be covered to match the learners’ current or potential scope of professional activities.
*Regularly scheduled programs should attach a completed
*Single courses should ld attach a Planning Agenda.
Regularly Scheduled Series Form.
3. COMPETENCIES: Identify the IOM, ACGME, ABMS, MOC and other competencies that are related to
the content of this educational activity.
Patient Care
Increased knowledge of diagnostic
methods
Improved diagnostic competence
Increased knowledge of
treatment methods
Improved treatment competence
Practice Based Learning &
Improvement
Increased knowledge on how to
evaluate scientific evidence and/or
to improve personal practice
Improved competence to evaluate
scientific evidence and/or to
improve personal practice
Medical Knowledge Advancement
Interpersonal & Communication
Review of knowledge base generally
Competence
recognized as current & applicable
Increased knowledge of methods to
Increased knowledge of new findings in
improve interpersonal relationships
basic and clinical sciences
and communication
Increased knowledge of how to perform
Improved interpersonal and
medically related research
Improved skills in performing medically
communication competence
related research
Quality Improvement
Utilize Informatics to support
decision making
Professionalism
Increased knowledge of medical ethics,
professional responsibilities, medico-legal
issues and/or sensitivity to a diverse patient
population
Improved skills regarding medical ethics,
professional responsibilities, medico-legal
issues and/or sensitivity to a diverse patient
population
Systems Based Practice
Increased knowledge about practice
management
Improved management/
administrative competence
Increased knowledge about multispecialty/multidisciplinary
coordination of care
Use of Interdisciplinary Teams
Revised:February 2011
3
4. EDUCATIONAL FORMAT: What teaching methodology will be used to achieve the key learning points listed
above?
Lecture w/ Q&A
Small Group Discussion
Panel Discussion
Case Discussion
Laboratory Activities
Other :
Demonstration
Interactive Programs
5. Are there non-education strategies that can serve as an adjunct to this educational activity?
6. List any outside factors or barriers that may impact the outcome of this educational activity.
7. Are there any other stakeholders we should collaborate with on this educational activity?
8. OUTCOMES MEASUREMENT: Based on the identified professional gap, what outcomes measurement will
be achieved as a result of this activity. In other words, what is the activity designed to change?
What method will you use to measure this?
Post-activity questionnaire
Pre and post-test to measure changes in knowledge, skills and/or behavior
Follow-up with participants to measure application of knowledge or skills
Assessment of health status data of patients in participant’s practice
Post-activity participant interviews
Quality data
Patient satisfaction surveys
Patient outcomes
Other (please specify)
How will this data be used?
F.
FACULTY INFORMATION
Include faculty information on Planning Agenda Form. Attach Curriculum Vitae for each presenter .
RSS EVMS faculty CVs remain in presenting department.
Revised:February 2011
4
G.
METHODS OF PROMOTION
Brochures
Flyers
Posters
Other
Electronic (e-mail/website)
Attach a draft flyer or brochure if available
ESSENTIAL AREA 3: ADMINISTRATION FOR THIS CME ACTIVITY
A.
PROPOSED BUDGET *CME Fees:
EXPENSES
Honoraria
$
Travel
$
Promotion
$
Food
$
CME Fees*
$
Total Expenses $
INCOME
Registration Fees
Educational Grants
Department Funds
Other (explain)
Total Income
Total Expected Profit/Loss
B.
$
$
REGISTRATION FEES:
Physicians
Medical Students, Residents
C.
$
$
$
$
Allied Health Professionals
Other (specify)
COMMERCIAL SUPPORT
1.
Is commercial support anticipated from a pharmaceutical company or other vendor?
Yes
No
If so, please list company and amount of contribution. Attach list if necessary.
Company
Representative
Amount
$
$
$
$
2.
Will any commercial vendor or other representative display during the conference?
Yes
No
PLEASE NOTE: All commercial support is centralized through the Office of CME and must comply with the
ACCME Standards for Commercial Support. Details of the EVMS-CME policy will be explained by the
Director of CME.
Revised:February 2011
5