REGULARLY SCHEDULED SERIES CME REQUEST FORM
To the Applicant:
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All applications must have an Ochsner physician serving as the activity director.
The activity director is responsible for assuring completion and compliance with the CME application process.
The activity director and the department chairman must sign the application.
The Ochsner CME department will review all applications for compliance with the ACCME criteria.
ACTIVITY INFORMATION
Name of Activity:
Frequency [weekly, monthly, day of week, time of day]:
Location: [The non-physician contact is responsible for reserving room, AV, video-conferencing, ordering food]
________________________________________________________________________
Activity Director(s): [must be an Ochsner physician]:
Address [for inter-office mail]:
Phone:
Fax:
E-mail:
_______________________________________________________________________
Non-Physician Contact Name[i.e. assistant, nurse, etc… ]:
Title:
Address [for inter-office mail]:
Phone:
Fax:
E-mail:
________________________________________________________________________
Joint or Co-Sponsor Organization [if applicable]:
Contact Person:
Phone:
Fax:
E-mail:
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Target Audience
Note: THE CONTENT OF YOUR PROGRAM MUST BE GEARED TOWARD PHYSICIANS. Although
other healthcare providers may attend, the majority of participants should be physicians.
Please list all specialties that should be targeted:
Target audience:
[ ] Internal to Ochsner Only
[ ] Non-Ochsner physicians invited
[ ] other_____________________
Needs Assessment (Criteria 2)
Please describe the needs assessment AND professional practice gap (The difference between
actual and ideal performance and/or patient outcomes) of the target audience for the educational
activity:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Using your statement above, please check the items below from which these needs were derived:
Competence (Knowing HOW to do something):
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New methods of diagnosis or treatment
Availability of new medication(s) or indication(s)
Development of new technology
Input from experts regarding advances in medical knowledge
Acquisition of new facilities or equipment
Legislative, regulatory, or organizational changes affecting patient care
Other, please describe:
Performance (What one actually DOES in practice):
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Requests submitted on participants’ activity evaluation forms
Formal surveys of potential participants (mail and Internet-based)
Previous Program evaluation tabulations
Patient problem inventories compiled by potential participants
Consensus of faculty members within a department or service area
Library requests
Delivery of care
Processes of care
Other, please describe:
Patient Outcome/Statistical Data
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] Epidemiological data
] Performance Improvement data
] Re-credential review
] Morbidity/mortality statistics
] Infection control data
] Surgical procedures statistics
] Other, please describe:
****Evidence of need for each resource noted in Criteria 2 must be attached. Applications submitted without
this required documentation will be returned without review.
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Desired Results (Criteria 3)
Please describe how this activity/educational intervention is designed to change
Competence (Knowing HOW to do something):
Performance (What one actually DOES in practice):
or
Patient outcomes:
Briefly describe the purpose, and content of the educational activity:
______________________________________________________________________________
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______________________________________________________________________________
Please list the learning objectives of the overall educational activity:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Scope of Practice (Criteria 4)
Please describe how the content of this activity matches the participants’ current or potential
scope of professional activities:
Educational Format (Criteria 5)
Please choose an educational format for the activity that is appropriate for the setting, objectives,
and desired result of the activity.
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] Lecture
] Interactive Workshop
] Laboratory Session
] Faculty Panel Discussion
] Question & Answer Session
] Case Studies
] Audiovisual aids (check applicable items):
slides
video
audio
] Syllabus/Handout Materials
] Medical images (e.g. X-Rays, CT, MRI, Nuclear Medicine, Ultrasound)
] Live Transmission (video conference, web cast, satellite, etc…)
] Other (briefly describe):
Program Schedule –Please provide a proposed annual calendar including proposed speakers and
topics.
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Desirable Physician Attributes (Criteria 6)
Select all desirable physician attributes this course will address
IOM Competencies
ACGME Competencies
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] Provide Patient-Centered Care
] Work in interdisciplinary teams
] Employ evidence-based practice
] Apply Quality Improvement
] Utilize informatics
] Patient Care
] Medical Knowledge and Skills
] Interpersonal and Communication Skills
] Professionalism
] System-Based Practice
] Practice-Based Learning and Improvement
Disclosure
Disclosure: Anyone that is on the planning committee or has control of the content or is engaged in
the decision making of this activity is required to complete a disclosure form. Please list all
speakers and planning committee members below:
CME Policies
Please refer to policy number OHS.ACR.009 for roles and responsibilities, honoraria,
commercial support, funding, and CME guidelines.
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Signature
Please sign below as Activity Director, then forward to your Department Chairman/Section Head for review and
signature. If the Activity Director is the Department Chairman/Section Head, please have your AMD review the
application and also sign below. Applications are reviewed by an assigned CME Meeting Planner; and a physician
liaison of the CME Executive Committee.
By signing below, I approve and recommend the implementation of this proposed CME activity and attest that the
activity will comply with the Criteria for compliance with ACCME’s Accreditation Elements, including such
requirements concerning content validity and scientific integrity.
Submitted by:
__________________________________________________________
Activity Director
Date
Reviewed by:
__________________________________________________________
Department Chairman/Section Head
Date
or AMD, if Department Chairman/Section Head is Activity Director
Please forward completed application and to:
For Interoffice Mail: EMC/ 4 /CME
(located at1201 S Clearview Blvd
on the fourth floor of the Elmwood Medical Center, Suite 402)
Ochsner Clinic Foundation
Continuing Medical Education Department
1514 Jefferson Highway
New Orleans, Louisiana 70121
Telephone (504) 842-3702 Fax (504) 842-4805
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FOR CME
Identification Number ______________
DEPARTMENT USE ONLY
Date Received: _________________________
Sponsorship: [ ] Directly Sponsored [ ] Jointly Sponsored
Classification: [ ] New [ ] Annual [ ] Other: (describe) ___________________
Assigned to:
_________________________________________
Sr. Meeting Planner, CME
After reviewing the application and disclosures:
[ ] Mission Statement (Criteria 1) This activity is congruent with the CME Department’s Mission
I [ ] recommend/ [ ] do not recommend planning as a CME activity. Comment Attached
Reviewed by: _________________________________________
CME Executive Committee Member
_____________
Date
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