Canadian Society of Internal Medicine
Société canadienne de médecine interne
300-421 Gilmour Street, Ottawa, ON K2P 0R5
Tel.: 613-422-5977 / Fax: 613-249-3326
Toll free: 1-855-893-CSIM (2746)
info@csim.ca
www.csim.ca
CSIM Application Form for MOC Appro val
Approval of Accredited Group Learning Activities:
Section 1 of the Framework of CPD Options of the Maintenance of Certification Program
Please ensure you are using the most recent MOC Application Form by clicking here to download.
Program Title:
Location of Program:
City
Province
Start Date
End Date
Program Dates:
PART #1: ORGANIZATION REQUESTING APPROVAL (see definition on page 2)
Activities submitted for approval under Section 1 must meet the requirements for either Option A or B.
Option A: Activities planned by a physician organization may be approved without being co-developed.
Option B: Activities planned by non-physician organizations must be co-developed by a physician organization or an
accredited provider. If you have selected Option B, please do not complete this application and refer to the paragraph
below on co-development and contact the CSIM Office.
If you do not meet the criteria in Option A or B, we will not be able to consider your application; the program is ineligible for
Section 1 credits. Other options for obtaining credit exist for CPD activities that have not been reviewed or approved; please
refer to the General Maintenance of Certification information on the Royal College website.
Co-Development: If you wish CSIM to consider a co-development program, please call the CSIM Office for more
information regarding the process. The first step prior to submitting an application will be to provide a “Letter of Intent”
outlining the project. The CSIM must have been involved in the planning process from the beginning. This includes
planning, the needs assessment, development of learning objectives, speaker selection, program design, implementation
and evaluation. This constitutes educational co-development. For co-development, CSIM must be contacted before any
planning commences. Note that a sponsor cannot take part in the planning process, be on the planning committee, select
speakers nor be involved in the development of learning objectives.
Is the program sponsored by a physician organization: Yes
No
If yes: Name of the physician organization:
Name of any non-physician organizations:
Chair of the Planning Committee Requesting Approval:
(Name of Physician)
Address:
City:
Province:
Postal Code:
E-mail:
Fax: (
)
Phone: (
)
Contact person and email to copy correspondence:
Is this event online-only: Yes
No
Is this a recurring activity: Yes
No
Number of times this activity will reoccur within one year from date of accreditation:
Page 1 of 8
Canadian Society of Internal Medicine
Société canadienne de médecine interne
300-421 Gilmour Street, Ottawa, ON K2P 0R5
Tel.: 613-422-5977 / Fax: 613-249-3326
Toll free: 1-855-893-CSIM (2746)
info@csim.ca
www.csim.ca
(A recurring event refers to one event occurring several times in the same year, with the same content, program, faculty,
objectives, etc. for each occurrence. If there is any variation, each event must be accredited separately.)
I have reviewed the Royal College Guidelines and process for physician organizations
NOTE: if a program is covering travel, accommodation or other personal expenses to participants, the program is not eligible
for Section 1 credits. For further information, please refer to Section 32 of the CMA Guidelines for Physicians in Interactions
with Industry (2007) and the Royal College interpretation which states: “All accredited group CME/CPD events cannot provide
funding for physicians or their families to travel to attend events or to pay for their lodging or other related costs.”
Physician Organization: A not-for-profit group of health professionals with a formal governance structure, accountable to
and serving, among others, its specialist physician members through:
 Continuing professional development
 Provision of health care; and/or
 Research
This definition includes (but is not limited to) the following groups:
 Faculties of medicine
 Hospital departments or divisions
 Medical (specialty) societies
 Medical associations
 Medical academies
 Physician research organizations
 Health authorities not linked to government agencies
 Canadian Provincial Medical Regulatory Authorities (MRAs)
This definition excludes pharmaceutical companies or their advisory groups, medical supply and surgical supply companies,
communication companies or other for-profit organizations and ventures/activities.
Types of organizations that are not considered Physician Organizations:
 Disease-oriented patient advocacy organizations (e.g. Canadian Diabetes Association)
 Government departments or agencies (e.g. Health Canada, Public health Agency of Canada)
 Industry (e.g. pharmaceutical companies, medical device companies, etc.)
 Medical education or communications (MEC) companies (e.g. CME Inc.)
 For-profit online educators, publishing companies or simulation companies (e.g. Medscape, CAE)
 Small number of physicians working together to develop educational programming
PART #2: MANDATORY EDUCATIONAL REQUIREMENTS
Criteria 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. Who is the target audience for this activity? Please indicate specific specialties and, if applicable, indicate other
health professionals for whom the activity is intended.
2. Every accredited CPD activity must have a scientific planning committee (SPC) that includes
representatives of the intended target audience. List all members of the planning committee, their medical
specialty or health profession, and indicate which are representing the physician organization?
3. What sources of information were selected by the planning committee to define the content of this activity? For
example, reviews of the scientific or education literature; clinical practice guidelines; surveys or focus groups
conducted by the sponsoring organization.
Page 2 of 8
Canadian Society of Internal Medicine
Société canadienne de médecine interne
300-421 Gilmour Street, Ottawa, ON K2P 0R5
Tel.: 613-422-5977 / Fax: 613-249-3326
Toll free: 1-855-893-CSIM (2746)
info@csim.ca
www.csim.ca
Optional
4. What gaps in knowledge, attitudes, skills, or performance did the planning committee identify for this event? For
example, physician performance information from hospitals or provincial / national databases; self-assessment tests;
case scenarios; quality improvement activities or audits of practice.

Criteria 2: The activity must create learning objectives to address identified needs. The learning objectives
must be printed in the program brochure/materials or in the online information. Objectives should clearly
state what a participant will know or be able to do as a result of attending an event or session. Click here for
information on creating learning objectives.
Please provide an explanation or supporting documentation for the following issues or questions:
1. What learning objectives were developed for this activity?
a) The overall event?
b) Specific sessions?
2. How were the identified needs of the target audience utilized in the creation/development of the learning objectives?
3. Do the learning objectives express what the participants will know or achieve by participating in the activity?
Yes
No
4. How are the learning objectives linked to the evaluation strategies for the activity? For example does the evaluation
form list the learning objectives or pose questions to participants about whether the learning objectives were met?
Criteria 3: At least 25% of the total education time must be devoted to interactive learning strategies.
Please send the proposed course schedule, with times, indicating discussion periods, workshops, small group sessions etc.,
and provide an explanation or supporting documentation for the following issues or questions:
1. What learning methods have been incorporated to promote interactive learning? For example, discussion periods,
small group, workshops or seminars, audience response system?
Criteria 4: The activity must include an evaluation of the event’s established learning objectives and the learning
outcomes identified by the participants.
Please provide a copy of the evaluation tools developed for this activity. The evaluation form should include opportunities for
the participant to identify what they have learned and its potential impact on stimulating further learning or for their practice
(i.e. Personal Learning Projects (PLPs); commitment to change). For information on evaluation, please click here.
Page 3 of 8
Canadian Society of Internal Medicine
Société canadienne de médecine interne
300-421 Gilmour Street, Ottawa, ON K2P 0R5
Tel.: 613-422-5977 / Fax: 613-249-3326
Toll free: 1-855-893-CSIM (2746)
info@csim.ca
www.csim.ca
Please provide a copy of the evaluation form and respond to the following questions:
1. Do you provide an opportunity for participants to identify if the stated learning objectives were achieved?
Yes:
No:
(If no, please revise accordingly before you submit, note that each learning objective must
be listed and evaluated separately.)
2. Are there opportunities for participants to identify and/or reflect on what they have learned? (One example of this
would be a questions asking what the participants learned or plan to integrate into their practice)
Yes:
No:
Optional (3, 4 and 5)
3. Does the evaluation strategy intend to evaluate enhanced participant performance.
Yes
No
If yes, please describe the tools or strategies used:
4. Does the evaluation strategy intend to evaluate improved health care outcomes?
Yes
No
If yes, please describe the tools or strategies used:
5. Will the participants receive feedback related to their learning?
Yes
No
If yes, please describe the tools or strategies used:
PART #3: MEETING ETHICAL STANDARDS FOR CONTINUING PROFESSIONAL EDUCATION
Group CME activities approved under Section 1 must meet the CMA Guidelines governing the relationship between
physicians and the pharmaceutical industry.
Any financial assistance provided to reimburse physicians or their families for attending the program for travel or
accommodation, will result in non-approval for this application. For more information on the guidelines regarding
sponsorship from Industry, please see the CMA Policy “Physicians and the Pharmaceutical Industry (2007) (sections 21-40).
1. The physician organization must have control over the topics and content of the activity, as well as the speakers
invited to present at the activity.
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 must assume responsibility for ensuring the scientific validity, objectivity, and
completeness of the content of the activity.
We comply with this standard
Yes
No
Describe the process to ensure validity and objectivity of the content for this event:
3. The sponsoring or co-sponsoring organization must disclose to participants all financial affiliations of faculty,
moderators or members of the planning committee (within the past two years) with any commercial organization(s)
regardless of its connections to the topics discussed or mentioned during the event
We comply with this standard
Yes
No
Describe how conflict of interest information is collected and disclosed to participants:
Page 4 of 8
Canadian Society of Internal Medicine
Société canadienne de médecine interne
300-421 Gilmour Street, Ottawa, ON K2P 0R5
Tel.: 613-422-5977 / Fax: 613-249-3326
Toll free: 1-855-893-CSIM (2746)
info@csim.ca
www.csim.ca
Note: Completed conflict disclosures from all speakers/faculty are required prior to an event. Conflicts, or lack
of conflicts, are to be disclosed on the second slide of the speaker’s presentation. The conflicts of the planning
committee are also to be disclosed; this could be done via handout to participants, handouts available at the
registration desk, listed within the program or online.
4. All funds received in support of this activity must be provided in the form of an educational grant payable to the
sponsoring organization.*
We comply with this standard
Yes
No
To whom is the Educational Grant been made payable:
Note: Accreditation statements cannot be located near any sponsorship recognition. Sponsorship recognition
cannot be located within the scientific content. The accreditation statement is to be located within the program.
Signage with sponsor recognition cannot be located within the room where the educational activity is taking place.
Please include a copy of the detailed budget for this program that identifies each source of revenue and each expenditure
for this event. Please describe how the physician organization(s) assumes responsibility for the distribution of these funds,
including the payment of honoraria to faculty.
Name of organization issuing any honoraria:
Please identify all organizations that are funding this activity. If necessary please use an additional page.
5. No drug or product advertisement may appear on or with any of the written material for this event.
We comply with this standard
6.
Yes
No
A) Generic names should be used on all presentations and written materials. If trade names are used they should be
accompanied by the generic name.
We comply with this standard
Yes
No
B) Describe the process to advocate speakers’ adherence to using generic names of medications and/or devices
included within all presentations or written materials.
We comply with this standard
Yes
No
Page 5 of 8
Canadian Society of Internal Medicine
Société canadienne de médecine interne
300-421 Gilmour Street, Ottawa, ON K2P 0R5
Tel.: 613-422-5977 / Fax: 613-249-3326
Toll free: 1-855-893-CSIM (2746)
info@csim.ca
www.csim.ca
DOCUMENTATION REQUIRED: ALL documentation must be included with your application to form a
complete application. Applications are to be submitted 8 weeks before program start date. Incomplete
applications will not be accepted.
Each item is to be sent as its own file. Have you included the following:
 Completed application form emailed to info@csim.ca Yes
 Detailed program Yes
No
No
 If applicable, the evaluation summary of this program from last year Yes
No
NA
 Learning objectives for each presentation Yes
No
 Detailed budget (Revenue sources and expenses need to be itemized) and sponsorship information (PDF sample)
*Note: ALL applications must use this budget template* Yes
No
 A copy of the evaluation form (each presentation is to be evaluated) Yes
No
 Completed conflict disclosures for all faculty/speakers/planning committee members Yes
No
Please name files consistently and clearly (“Smith_John_COI.pdf”)
 Conflict disclosure summary (sample) Yes
No
 Copy of the certificate of attendance/participation Yes
No
 Application Fee Yes
No
 Needs Assessment Yes
No
 The speaker(s) has disclosed / will disclose any conflicts in their 2nd slide. If there is nothing to disclose, this should be
stated Yes
No
 For online programs, I have reviewed the document Criteria for approval of Online CPD Events for Maintenance of
Certification Yes
No
 For co-developed applications only: a copy of the minutes of the planning committee Yes
No
 For co-developed applications only: the completed co-development checklist Yes
No
 If your event is being held in Quebec, as per the Conseil québécois de développement professionnel continu des
médecins, passport or draws as incentives to visit the exhibits are prohibited. For events in Québec, I have reviewed
the CQDPCM Code of Ethics Yes
No
DECLARATION: As the course planner I accept the responsibility for the accuracy of the information provided in
response to the questions listed on this form and, to the best of my knowledge, certify that the CMA’s guidelines, entitled
“Physicians and the Pharmaceutical Industry (2007) (sections 21-40) have been met in preparing for this CPD event.
I confirm that the required documentation is complete and attached.
If this event is held in Québec, we are aware that it is mandatory to adhere to the Conseil québécois de développement
professionnel continu des médecins (CQDPCM) (CQDPCM), Code of Ethics for parties involved in Continuing Medical
Education.
I have reviewed the CSIM document “The Role of the Canadian Society of Internal Medicine in the Approval and CoDevelopment of CPD Activities” located on the CSIM website www.csim.ca.
Chair of the planning committee:
Print name:
Signature:
Date:
NOTE: Applications will not be reviewed until all documentation and fees are included. The date of review
commences on the date the completed application is received. The application fee is non-refundable even in the event the
application is declined. If the application is approved, this fee will be applied to the full accreditation fee.
Page 6 of 8
Canadian Society of Internal Medicine
Société canadienne de médecine interne
300-421 Gilmour Street, Ottawa, ON K2P 0R5
Tel.: 613-422-5977 / Fax: 613-249-3326
Toll free: 1-855-893-CSIM (2746)
info@csim.ca
www.csim.ca
In order to give CSIM the opportunity to adequately review your program and make any suggestions for improvement,
please submit your application as soon as possible in advance of the event. Please allow up to eight (8) weeks for Section 1
review and approximately six (6) months for co-development applications.
Applications submitted five weeks from the start date of the program may be rejected. Upon exception, the application may
be reviewed as a rush and an Expedited Accreditation Fee will be applied. If you have a rush application, please contact
the CSIM prior to submission of the application. Applications submitted three weeks or less from the start date will not be
considered. Co-developed programs are not eligible for expedited review.
FEE STRUCTURE
PROVIDER
ACCREDITATION PROCESS
(Section 1 and Section 3)
FEE
NON-REFUNDABLE
APPLICATION FEE*
Physician organization
No private sector funding
of the event
Section 1 Approval
$750
(plus HST)
$100
(plus HST)
Physician organization
With private sector funding
for the event
Section 1 Approval
$1,250
(plus HST)
$200
(plus HST)
Physician organization
Section 3 Approval
$1,250
(plus HST)
$200
(plus HST)
Educational co-development
where CSIM would be represented
on the planning committee from
the onset of planning.
$8,000
Non-physician organization
$750
(plus HST)
Plus a $2,000 Administration fee
For recurring events only: $300
Maintenance Fee per each
recurrence
(taxes apply to all fees)
Note: Additional administration fees may apply for changes relating to the application and invoicing process.
* Non-refundable application fee must accompany the application (if approved, this fee will be applied to the full accreditation fee)
APPLICATIONS FOR CO-DEVELOPMENT CONSIDERATION: Please include a non-refundable application fee of $750 +
HST for consideration of co-development applications. Should your application be approved, the application fee will be
applied to the accreditation fee. In the event that a co-developed program does not take place or is declined, the nonrefundable application fee and the administration fee will not be refunded. Refer to page 1 for more information regarding
co-development and to CSIM’s document entitled “The Role of the Canadian Society of Internal Medicine in the Approval
and Co-Development of CPD Activities” for more information.
The completed application and documentation is to be sent electronically to info@csim.ca. Refer to CSIM’s “The Role of the
Canadian Society of Internal Medicine in the Approval and Co-Development of CPD Activities” for more information.
The applicant should keep an electronic copy of the completed application form and submitted documentation.
The non–accredited provider has the responsibility for maintaining and documenting an ethical relationship with industry
supporters; maintaining records of the evaluations and participation rests with the non-accredited provider.
Section 1 approval is valid for 12 months.
Page 7 of 8
Canadian Society of Internal Medicine
Société canadienne de médecine interne
300-421 Gilmour Street, Ottawa, ON K2P 0R5
Tel.: 613-422-5977 / Fax: 613-249-3326
Toll free: 1-855-893-CSIM (2746)
info@csim.ca
www.csim.ca
GENERAL INFORMATION
 Applications may NOT be submitted after an event.
 Applicants should keep a list of their attendees for record purposes for a period of five (5) years.
 The non-accredited provider is to maintain records of CPD activity (materials, attendance) and submit information to the
Validation Program on request by the Royal College.
 General Maintenance of Certification information can be found on the Royal College website.
 Notice of approval of this activity will be forwarded to the Royal College of Physicians and Surgeons of Canada in order
to list your event on the Royal College web site. The College will also be notified of applications that are declined.
 Click here for the Royal College Accreditation Tool Kit.
 Guidelines for Accredited Providers of CPD Activities
SELF-ASSESSMENT PROGRAMS (SAPs): For a copy of CSIM’s SAP Application Form, please click here or visit
www.csim.ca. Click here for Royal College information on self-assessment programs.
The non-refundable deposit must accompany your application form.
I have sent a cheque to CSIM for:
Deposit
Full fee
Please email an invoice.
Please advise the CSIM office promptly if you do not receive a Notice of Receipt of Submission within 48 hours of
submission. It is the applicant's responsibility to ensure the completed application is received.
CSIM CPD SUB-COMMITTEE MISSION STATEMENT
“Our ultimate goal is to go beyond the simple transmission of information. Our goal is to make a
lasting impact on the knowledge, skills and attitudes of clinicians and future clinicians; to narrow the theory
to practice gap; to improve the health of our patients and of all Canadians.”
December 22, 2015
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