CME Planning/Application Form
Office of Continuing Medical Education
4610 X Street, Suite 2301, Sacramento, CA 95817
Phone: (916) 734-5390 Fax: (916) 734-3580
This form collects information needed to plan and develop a CME activity that improves patient care and meets
accreditation requirements. Completed forms and attachments are required six months before the proposed activity date.
CME Planning Form Guidelines are provided to answer common questions. CME staff is available to assist you as needed.
SECTION 1: ACTIVITY DESCRIPTION
TITLE:
PROPOSED DATE(S):
PROPOSED LOCATION:
ESTIMATED HOURS OF CE:
ESTIMATED ATTENDANCE:
ESTIMATED # OF FACULTY:
ACTIVITY TYPE [C5]
Select the appropriate type for a live activity, an enduring material, or one of the other activity types listed below.
LIVE ACTIVITY
If live activity will be recorded and released as an enduring material
Course with Full Service by OCME
with CME credit, complete the following:
Course with Credit Only
Format:
Internet
CD-ROM
Print
Other:
Live Internet Webinar
Anticipated release date:
Regularly Scheduled Series
Recording by: Department
Contracted Service:
ENDURING MATERIAL
ADDITIONAL ACTIVITY TYPES
Internet
Journal-based CME
CD-ROM
Test-item Writing
Print
Manuscript Review
Other:
Performance Improvement (PI)
Internet Point-of-Care
To Be Completed for Regularly Scheduled Series Only
Grand Rounds
Will this be televised to telesites?
No
Yes
Case Conferences/Tumor Boards
RSS previously approved?
No
Yes
Morbidity & Mortality Conferences (M&M)
If yes, previous course code:
Journal Club
SCHEDULE
Start time:
Frequency:
Day of the week:
End time:
Rationale for selecting activity type
TARGET AUDIENCE: Check all that apply [C2]
Geographic Location
Provider Type
Internal only
Primary care physicians
Local/Regional
Specialty physicians
National
Pharmacists
International
Psychologists
Physician assistants
Nurses
Nurse Practitioners
Other (specify):
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All specialties
Anesthesiology
Cardiology
Dermatology
Emergency Medicine
Family Medicine
General Medicine
Neurology
OB/GYN
Specialty
Oncology
Orthopaedics
Pediatrics
Psychiatry
Radiology
Radiation Oncology
Surgery
Other (specify):
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ACTIVITY DESCRIPTION
Please provide a 4-5 sentence paragraph that describes the overall educational purpose and goal of this activity.
SPONSORSHIP
Direct: OCME and UCD department/division and, if applicable, an outside accredited entity involved in planning
Joint: OCME and UCD department/division and non-UCD, non-accredited provider involved in planning
Identify joint provider(s):
TYPE OF CREDIT REQUESTED
Note: Only AMA/PRA Category 1 available for RSS
American Medical Association AMA/PRA Category 1 CreditsTM
American Academy of Family Physicians (AAFP): AAFP member must be involved in planning the activity
Accreditation Council for Pharmacy Education (ACPE): Pharmacist must be involved in planning the activity
California Board of Behavioral Science (BBS): LCSW/MFT
Other (specify):
COMMERCIAL SUPPORT (EDUCATIONAL GRANTS) AND EXHIBIT FEES [C 7, 8, 9, 10]
Activity directors agree to develop this activity independent of commercial interests and according to accreditation requirements.
All commercial support is managed by the OCME. Letters of Agreement for educational grants must be signed by the OCME
representative. The OCME maintains separation of promotion from education; therefore exhibit fees are also managed by OCME.
Yes
No Do you plan to solicit educational grants?
If yes, please identify companies:
Yes
No Do you plan to solicit exhibit fees?
If yes, please identify companies:
SECTION 2: LEADERSHIP AND ADMINISTRATIVE SUPPORT
ACTIVITY DIRECTOR OR COURSE CHAIR
Physician or base scientist who has overall responsibility to plan, develop and implement the activity
Name/Degrees:
Title:
Department:
Division:
Address:
Phone:
Email:
Administrative Contact:
Phone:
Email:
ACTIVITY CO-DIRECTOR OR COURSE CO-CHAIR (if applicable)
Individual who shares responsibility to plan the activity.
Name/Degrees:
Department:
Address:
Phone:
Title:
Division:
Email:
ADMINISTRATIVE COORDINATOR/CME ASSOCIATE
Individual responsible for operational and administrative support of the activity (i.e. staff assistant in director’s department)
Name/Degrees:
Title:
Department:
Division:
Address:
Phone:
Fax:
Email:
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PLANNING COMMITTEE (if applicable) Others responsible for designing and implementing the activity
Name/Degrees:
Title:
Institution/Department/Division:
Name/Degrees:
Email:
Title:
Institution/Department/Division:
Email:
UCD Employee
Yes
No
UCD Employee
Yes
No
ALIGNMENT WITH UCDHS CME MISSION STATEMENT [C3]
Our CME activities are designed to change competence and/or performance and/or patient outcomes as described in our mission
statement. This activity is designed to: (check all that apply)
Assist physicians and healthcare professionals gain competence and improve performance to become better able in providing
quality care in order to change patient outcomes and improve lives
Address professional practice gaps of identified specialties and/or the interprofessional health care team
Assist in the dissemination of new medical knowledge
Promote the practice of evidence-based medicine
Address Faculty Development issues
Promote Inter-professional education
Other (specify):
SECTION 3: GAPS, NEEDS ASSESSMENT AND OBJECTIVES [C2, 3]
Practice gaps refer to the variance between what the target audience is currently doing in practice and what they should be doing.
Said another way, a gap is a problem, issue, challenge, etc. Gaps can be in terms of knowledge (lack of awareness of something),
competence (not knowing how to do something) or performance (not actually doing something). The educational need is the cause
or reason for the gaps. Objectives state the results of the activity, what the activity is designed to change in terms of what learners
should be able to do to close the gaps and meet their needs. Please state gaps, needs, objectives, etc. for topic and/or major topic
areas.
GAP
This
NEED
Learning Objective
The difference between current
Identifies
Cause or reason for the gap.
What learners should be able to do (in
practice and desired or optimal
a Gap in: Knowledge causes, competence causes
terms of changes in competence,
practice. Problem, issue,
or performance causes.
performance or patient outcomes) as a
challenge to be addressed.
result of attending this CME activity.
What is the problem or issue (gap)?
Knowledge
Competence
Performance
Why does the gap exist? What educational
needs (knowledge, competence,
performance) should be addressed to close
the gaps?
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The solution to address or fix the problem
or issue. After attending this activity,
participants should be able to:
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What sources did you use to identify the needs? Please list and attach examples (journal article, CDC guidelines, etc).
What is the problem or issue (gap)?
Knowledge
Competence
Performance
Why does the gap exist? What
educational needs (knowledge,
competence, performance) should be
addressed to close the gaps?
The solution to address or fix the problem
or issue. After attending this activity,
participants should be able to:
What sources did you use to identify the needs? Please list and attach examples (journal article, CDC guidelines, etc).
What is the problem or issue (gap)?
Knowledge
Competence
Performance
Why does the gap exist? What
educational needs (knowledge,
competence, performance) should be
addressed to close the gaps?
The solution to address or fix the problem
or issue. After attending this activity,
participants should be able to:
What sources did you use to identify the needs? Please list and attach examples (journal article, CDC guidelines, etc).

If more fields for reporting gaps is needed, please find an additional page at the end of this form
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SECTION 4: CONTENT DEVELOPMENT
IDENTIFIED BARRIERS AND STRATEGIES TO BE ADDRESSED [C18, 19]
What are the real or potential barriers that may prevent learners from achieving changes in competence, performance or patient
outcomes? Select all that apply by checking below.
Lack of time to assess or counsel patients
Lack of consensus on professional guidelines
Lack of administrative support/resources
Cost
Insurance/reimbursement issues
No perceived barriers
Patient compliance issues
Other (specify):
Describe how you will attempt to address these identified barriers in the activity:
COLLABORATION AND COOPERATION [C20]
Inter-professional teamwork and team based patient care can improve health care quality and patient safety. Who else should be
included in the planning and delivery of this activity to promote team learning and how will you include them? Are there internal
and/or external stakeholders that could be included in the planning process?
Yes
No. If yes, please explain.
QI/Patient Safety
Patients
Nurses
How will collaboration enhance the activity’s intended outcomes:
Pharmacists
Dentists
Social Workers
Physician specialists
Primary care physicians
Outside organizations
QUALITY IMPROVEMENT [C21]
We encourage you to think about ways to incorporate quality improvement measures into the planning of this CME activity.
Will the content of this activity include or address one or more of the measures below?
Yes
No.
If yes, please check the appropriate box(s) and describe.
Institutional Quality Goals
Patient Safety
Sentinel Events
Performance/Quality Improvement Measures
Specialty Society Quality Goals
Other quality improvement metrics
CULTURAL AND LINGUISTIC COMPETENCY
Select one or more areas of emphasis you will implement to address this competency as required by California Business and
Professions Code, Section 2190.1.
Apply linguistic skills to communicate effectively with target
Incorporate translation resources and/or integrate relevant
population
strategies into course materials
Use cultural information to establish therapeutic relationships
Incorporate review and explanation of relevant regulations
regarding linguistic access
Elicit and incorporate pertinent cultural data in diagnosis and
Other (specify):
treatment
Understand and apply cultural and ethnic data to the process
Not applicable to activity content (if checked, please explain):
of clinical care
PAIN MANAGEMENT
Select one or more areas of emphasis you will implement to address this competency as required by California Business and
Professions Code, Section 2190.5.
Pain management
Care of terminally ill and dying patients
N/A to activity content
GERIATRIC CARE
Select one or more areas of emphasis you will implement to address this competency as required by California Business and
Professions Code, Section 2190.3.
Geriatric medicine
Care of elderly patients
N/A to activity content
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SECTION 4: CONTENT DEVELOPMENT
DESIRABLE PHYSICIAN ATTRIBUTES/CORE COMPETENCIES [C6]
CME activities are developed in the context of desirable physician attributes. Check below to identify American Board of Medical
Specialties (ABMS)/Accreditation Council for Graduate Medical Education (ACGME) or Institute of Medicine (IOM) core competencies
to be addressed in this activity. Briefly describe activity content related to competencies identified.
COMPETENCY
CONTENT (e.g. lecture title; workshop, discussion, panel, etc)
Provide patient care or patient-centered care
Medical knowledge
Practice-based learning and improvement
Interpersonal and communication skills
Professionalism
System-based practice
Work in interdisciplinary teams
Apply quality improvement
Utilize informatics
Employ evidence-based practice
SECTION 5: EDUCATIONAL FORMAT
EDUCATIONAL FORMAT [C5]
Select the educational format(s) that will be used to facilitate change in competence, performance or patient outcomes.
Check all that apply and provide rationale.
METHODS TO ENGAGE LEARNERS
RATIONALE FOR FORMAT
Case studies
Audience response system
Panel discussion with Q&A
Debate
Hands-on lab sessions
Simulation
Small work groups
Other:
Lecture with Q &A
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ADDITIONAL RESOURCES TO REINFORCE LEARNING [C17]
Attendees place great value on additional resources or tools that they
can use. Are there additional resources such as the ones listed here
that could be provided to learners to enhance change as an adjunct to
this activity?
Yes
No If yes, please describe how they will be provided to
learners.
Reminder systems, checklists
Newsletters, booklets, DVDs
Posters, safety flip charts
Patient assessment tools
Post activity follow up
Algorithms, clinical protocols
Pocket card guidelines
Patient educational material
Other:
SECTION 6: EVALUATION AND OUTCOMES ASSESSMENT
EVALUATION AND OUTCOMES MEASUREMENT [C3, C11]
How will you measure if changes occur in competence, performance, and/or patient outcomes? Check all that apply.
COMPETENCE
Evaluation form for participants (required)
Physician and/or patient surveys
Audience response system (ARS)
Case Based Test
Customized pre/post-test
Other (specify):
PERFORMANCE
Demonstration of adherence to guidelines
Chart audits
Direct observations
Other (specify):
Customized follow-up survey/interview/focus group
about actual change in practice at specified intervals
PATIENT OUTCOMES
Observed changes in health status measures
Observed changes in quality/cost of care
Measure mortality and morbidity rates
Patient feedback and surveys
Other (specify):
OUTCOMES ASSESSMENT
A. Do you have plans to follow up with the participants for a post-activity outcomes assessment?
B. Would you be willing to partner with OCME to develop a post-activity outcomes assessment?
Yes
Yes
No
No
Please provide signature and date below:
Activity Director or Course Chair Signature_______________________________________ Date___________________
If available at this time, attach the activity agenda and other materials for review.
The CME Advisory Committee approves all requests.
Course chairs will be notified after committee review.
OCME USE ONLY: Date Application Received: ____________ Date Reviewed: _____________ Approved By: _________
CME Specialist Assigned: ______________ Date Approved by OCME: ___________
Type of Activity: Annual _____ New _____ Other _____ Full Service _____ Credit Only _____ RSS______
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Type of Sponsorship:
Direct ___ Joint ___ Type of Credit: CME ___ Pharmacy ___ Nursing ___ BBS ___ AAFP ___ Other _____
Grants? Yes
No
Exhibit Fees? Yes
No
Responsible department ___________________________
Notes: _____________________________________________________________________________________

What is the problem or issue (gap)?
Additional space for Section 3 gaps if necessary:
Knowledge
Competence
Performance
Why does the gap exist? What
educational needs (knowledge,
competence, performance) should be
addressed to close the gaps?
The solution to address or fix the problem
or issue. After attending this activity,
participants should be able to:
What sources did you use to identify the needs? Please list and attach examples (journal article, CDC guidelines, etc).
What is the problem or issue (gap)?
Knowledge
Competence
Why does the gap exist? What
educational needs (knowledge,
competence, performance) should be
addressed to close the gaps?
S:\CHT\Cme\FORMS\Forms - ACCRED\Planning-Document-App-07162014.docx
The solution to address or fix the problem
or issue. After attending this activity,
participants should be able to:
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Performance
What sources did you use to identify the needs? Please list and attach examples (journal article, CDC guidelines, etc).

What is the problem or issue (gap)?
Additional space for Section 3 gaps if necessary:
Knowledge
Competence
Performance
Why does the gap exist? What
educational needs (knowledge,
competence, performance) should be
addressed to close the gaps?
The solution to address or fix the problem
or issue. After attending this activity,
participants should be able to:
What sources did you use to identify the needs? Please list and attach examples (journal article, CDC guidelines, etc).
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What is the problem or issue (gap)?
Knowledge
Competence
Performance
Why does the gap exist? What
educational needs (knowledge,
competence, performance) should be
addressed to close the gaps?
The solution to address or fix the problem
or issue. After attending this activity,
participants should be able to:
What sources did you use to identify the needs? Please list and attach examples (journal article, CDC guidelines, etc).
S:\CHT\Cme\FORMS\Forms - ACCRED\Planning-Document-App-07162014.docx
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