Agency CME Approval Form (Year
Agency Full Name:
Agency Acronym (if used):
)
SCoP Use Only
Date:
Address:
Sector:
Health – EMS
Health – Other
Feedback provided
Initial:
Fire
Industrial
Date:
Approved
Initial:
Other
Health Region:
Contact Name:
Phone: (306)
FAX: (306)
Office Location:
Email:
AGENCY CONTINUING MEDICAL EDUCATION PROGRAM (Year ____________)
CME Program Priorities/Goals:
Meet recertification requirements
Increase skills to NOCP levels (eg. EMR, PCP)
Understand best practices in EMS
Introduce new technologies
Learn new protocols
Learn new skills
Address issues raised by Call Reviews
Other, list:
Registration and Record Keeping System
Describe your approach for each of the following:
1.
Registration and tracking of PARTICIPANTS throughout the year, including verification of practitioner attendance at
individual sessions, and reporting total practitioner activity.
2.
System to track and report participant SUCCESSFUL COMPLETION including issuing and maintaining records of
assessment or test results, transcripts, certificates, CME credits. (eg. what controls are in place to ensure accuracy and enable
verification).
3.
Retention of PARTICIPANT records/files—What is kept on file, how is it maintained, how long is it kept, how is accuracy
ensured, how is it kept secure? Who has access to the files/records?
4.
Retention of COURSE records/files—What is kept on file (i.e., Course outline, instructional materials, exams, participant list),
for how long?
5.
Oversight—How will professional oversight be provided to ensure the course is delivered as planned, the course is kept current,
and medical oversight is provided if needed?
Are you willing to have this form posted on the SCoP website for others to
see?
Yes
No
Is this agency CME be available for others to use?
Yes
No
If yes, how would they access it?
Estimated Number of
Practitioners by Level:
Mandatory Certifications
Program Source
EMRs
BLS-HCP (C)
EMTs
ITLS Basic
EMT/PCPs
EMT-As
EMT-A/ICPs
ITLS
Advanced
ACLS
EMT-Ps
EMT-P/ACPs
PALS or PEPP
In-house
Contracted for your agency
Practitioners to secure course
In-house
Contracted for your agency
Practitioners to secure course
In-house
N/A
Contracted for your agency
Practitioners to secure course
In-house
N/A
Contracted for your agency
Practitioners to secure course
In-house
N/A
Contracted for your agency
Practitioners to secure course
I declare that this agency CME description is accurate; that I take responsibility to ensure it is delivered as described; and that the course may be audited at any time by SCoP.
Signature: ____________________________
Address:
Print Name:
Agency:
Phone: (306)
Email:
Agency CME Approval Form (Year
)
Course/Seminar Title:
Course/Seminar Title:
Developed By:
Developed By:
Qualifications:
Qualifications:
Proposed CME Credits
to be awarded:
Estimated Duration in Minutes:
Date developed or revised:
Intended for: (Check all that apply)
30min
90min
60min
>120min
EMR EMT PCP EMT-A ICP
Proposed CME Credits
to be awarded:
Estimated Duration in Minutes:
Date developed or revised:
Intended for: (Check all that apply)
30min
90min
EMT-P ACP
60min
>120min
EMR EMT PCP EMT-A ICP
Quality Assurance Standards:
Instructor Qualifications:
Instructor Qualifications:
Required Equipment (for Skills Stations/Simulations):
Required Equipment (for Skills Stations/Simulations):
Substantive Course Objectives
Substantive Course Objectives
(how is this relevant to emergency medical practice)
(how is this relevant to emergency medical practice)
Instructor Qualifications:
Instructor Qualifications:
At level of participants
At and/or Above Level of participants
---------------------Knowledge in Topic Area
Adult Education Experience (instructor)
(CPR/ITLS/ACLS, etc.)
-----------------------Expert in Subject Material (RT, Dr., etc.)
At level of participants
At and/or Above Level of participants
---------------------Knowledge in Topic Area
Adult Education Experience (instructor)
(CPR/ITLS/ACLS, etc.)
-----------------------Expert in Subject Material (RT, Dr., etc.)
Evaluation of Participants:
Written/Online Exam
Skills Assessment
Scenario Assessment
Participation
No Evaluation
Evaluation of Participants:
Written/Online Exam
Skills Assessment
Scenario Assessment
Participation
No Evaluation
Instructor to Student Ratio for Skills
Stations or Simulations:
Instructor to Student Ratio for Skills
Stations or Simulations:
1:
1:
Course materials provided:
Literature
Interactive Learning Aids
(manikins, computer software, etc.)
Live clinical experiences, simulation labs, etc.
Course materials provided:
Literature
Interactive Learning Aids
(manikins, computer software, etc.)
Live clinical experiences, simulation labs, etc.
Instructional Methods to be Used:
Lecture/ Presentation
Skills Stations/Simulations
Scenarios
Discussion
Video/Online
Independent Study/ Reading
Other: (Specify)
Instructional Methods to be Used:
Lecture/Presentation
Skills Stations/Simulations
Scenarios
Discussion
Video/Online
Independent Study/ Reading
Other: (Specify)
Will transcripts or certificates be issued?
Yes
No
Will transcripts or certificates be issued?
SCoP Use ONLY
SCoP Use ONLY
TOTAL CME Credits Approved:
TOTAL CME Credits Approved:
Reviewed:
Follow-up:
EMT-P ACP
Quality Assurance Standards:
Approved:
Reviewed:
Follow-up:
Yes
No
Approved:
Two (2) Courses/Page