1
# of Credits or CEUs requested_______________
NEOMED APPLICATION FOR CE ACTIVITY
FOR OFFICE OF CPE USE ONLY
ACCME_
Date Rec'd
Application Fee $
*
Date Reviewed
File Name_
ACCME Credits Approved
ACCME: Competence/Performance/Patient Outcomes
*Fee is Non-refundable
ACPE__
ACPE Credits Approved
How is change measured?
ACPE Type: Knowledge/Application/Practice
A.
I am requesting: ______Pharmacy credit ______ Medicine credit
B.
Sponsoring Department/Division
C.
Joint or Co-Sponsor (if any)
D.
Activity Title
E.
Activity Dates (attach activity agenda to application)
F.
Activity Location
G.
Activity Director (must be a member of NEOMED faculty)
1.
2.
3.
4.
Name
Phone number
Office address
E-mail
Faculty
Status
Fax:
H. Program Planning Committee Members (must include one faculty member in addition to the activity director &
a CPE staff member from NEOMED). All Planning Committee Members are required to complete a disclosure
form which must be submitted with this application. Attach a complete list of members. Attach disclosures
Name
Faculty Status/Position
I.
What Professional Practice Gaps have been identified for this activity? Describe the gap in the context of the
data sources and documentation being provided. (If using committee recommendations they must be supported
by organizational data or national physician performance data.)
J.
Target Audience
1.
This program is planned to meet the needs of what group(s) of health care professionals?
2.
3.
Other Professionals:
Please describe the scope of the audience (e.g., local, national, international).
2
K.
Needs Assessment
What educational needs or deficits were derived from the professional practice gap(s) that you identified? Describe the
educational need you are addressing in order to close the professional practice gap. (Knowledge, competence,
application and/or performance)
Attach an explanation of gaps identified and how they will be addressed
L.
Learning Objectives
What are the specific learning or performance objectives of this program/activity?
Objectives should describe the expected change in terms of competence, performance and/or patient outcomes.
Attach an objective for each topic .
(If this activity is intended for audiences other than pharmacists separate learning objectives for those audiences must
be provided.)
M. Competencies and Areas of Proficiency:
What desirable attribute, competencies or areas of proficiency are incorporated into the content?
Please use the attached JCPP competencies as a guide in developing content appropriate for pharmacists.
Check one or more as appropriate.
IOM/ACGME Competencies and ACPE Five core areas of proficiency
(Check all addressed in this activity)
____
____
____
_____
_____
_____
_____
N.
Patient-Centered Care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health.
Medical Knowledge about established and evolving biomedical, clinical,
and cognate (e.g. epidemiological and social-behavioral) sciences and the
application of this knowledge to patient care.
Practice-Based Learning and Improvement/Evidence-Based Practice
that involves investigation and evaluation of their own patient care,
appraisal and assimilation of scientific evidence, and improvements in
patient care.
Interpersonal and Communication Skills/Work in Interdisciplinary
Teams that result in effective information exchange and teaming with
patients, their families, and other health professionals
Professionalism, as manifested through a commitment to carrying out
professional responsibilities, adherence to ethical principles, and
sensitivity to a diverse patient population.
Systems-Based Practice/Quality Improvement, as manifested by
actions that demonstrate an awareness of and responsiveness to the larger
context and system of health care and the ability of effectively call on
system resources to provide care that is of optimal value.
Utilize Informatics/Information technology – manage knowledge and
support decision making using information technology.
Instructional Methods/Materials
What instructional method(s) will facilitate the proposed changes in competence, performance or patient outcomes in
your learners? (Check all that apply)
Lecture
Laboratory activities
Small group discussion
Question/answer sessions
Patient rounds
Panel discussion
__
Case presentation
_______ Standardized Patient
Direct observation in practice
______ Other (please define)
Describe how the presentations will be interactive with the audience. In other words, how will active learning take place?
3
O.
Describe how you will assure and document that there will be no commercial bias or copyright violations in this
activity.
P.
Faculty
Attach a list identifying faculty by name, title, credentials, and institution. All faculty are required to complete a
disclosure form, which must be submitted with this application. When possible, NEOMED faculty are to be
involved as presenters, moderators, and/or panel members.
Attach a list including faculty information, include disclosure forms
Q.
Proposed Outcomes
What are your expected outcomes for this activity (in terms of competence, performance and/or patient
outcomes)? Do your expected outcomes relate back to your learning objectives? Keep in mind that intent to change
practice is not sufficient.
How will you determine the level to which you met your expected outcomes?
For example, you may consider using, but are not limited to the following methods: audience response system (if used
with case-based discussions it measures competence); QI data; demonstration; evaluation by students of a faculty
member; evaluation by patients of a physician or pharmacist.
R.
Have you considered how you might improve the impact of this activity by collaborating with an internal or external
group on this topic?
____Yes ___No
1. If yes, with whom and how will you collaborate?
2. If no, why not?
S.
What potential barriers do you believe exist that might prevent the learners’ from achieving the expected change in
competence, performance, or patient outcomes as a result of this activity?
What strategies could be used to remove or overcome these potential barriers?
4
T.
Finances (Final budget to be sent to Office of CPE after program is completed)
1.
Estimated enrollment
2.
Tuition/fee per participant $
3.
Estimated commercial support
*Educational Grants (estimated)
*Exhibitors (estimated)
$
$
Total anticipated registration fees
Department funds
Other (
)
$
$
$
TOTAL $
*Must abide by ACCME & ACPE guidelines for commercial support
4.
Estimated Expenditures
(List speaker name, honorarium fee, and travel in column provided. Attach sheet if necessary.)
Speaker
Honorarium
Travel
$
$
$
$
Total Speaker Costs
$
Brochures, mailing labels, etc.
$
Syllabus/handouts, etc.
$
Food/refreshments/room rental
$
OCPE Fee (Administrative)
$
OCPE Program Mgmt Fee
.
$
Other (personnel, office supplies, shipping, bank fees, etc.)
$
TOTAL $
5.
U.
Person to Contact Regarding Application
1.
2.
3.
V.
Any deficit will be paid by
Any surplus revenue will be
(Include account number if sponsored by a NEOMED department)
Name
Office address
Fax #
Phone #
E-mail
Record-Keeping System Policy
Following completion of the CE program, a copy of the attendance record must be submitted to the CPE office with
a copy of the summary of the evaluations, a final income and expense report, as well as any program handouts. The
Office of CPE will be responsible for making records available to physicians and pharmacists when required by their
licensing agencies to verify credits.
5
W.
Attachments
Attach the following to this application:
 Program Agenda/Time Frame
 Documentation of Needs Assessment Process
 Learning objectives
 Faculty information
 All Disclosure Forms
 Copyright Form(s)
X.
Program Responsibility
Two signatures are required:
 The Activity Director
 NEOMED Department or Division Chairperson
1.
Activity Director (must be NEOMED faculty). I am aware of the criteria for Category 1 CME
designation OR Continuing Education for the Profession of Pharmacy designation and agree to comply
with these criteria.
(Activity Director Signature)
Date
Type or print name and faculty rank
2.
NEOMED Department/Council/Section Chairperson (as appropriate). I have reviewed the educational
and administrative components of this continuing education activity and recommend on behalf of our
eligible unit that this activity be approved.
(Chair/Director Signature)
Date
Type or print name and title
Note: The Office of Continuing Professional Education reserves the right to deny CME or Pharmacy Continuing Education
credit to an activity at any stage of the program planning and implementation process. Any activity that does not have
complete and accurate documentation to the NEOMED Office of Continuing Professional Education three (3) months after
the course has ended may be denied accreditation certification.
Return to NEOMED, Continuing Professional Education Office. If you have questions, call (330) 325-6578.
Revised 6/11