Office of Continuing Medical Education
960 East Third Street, Suite 104 ∙ Chattanooga, TN 37403
(423) 778-6884 ∙ Fax (423) 778-3673
www.utcomchatt.org/cme
CME Activity Closeout Form
INSTRUCTIONS: Use this form to close-out the CME documentation for your UTCOM-certified CME activity, and to
request issuance of the CME credit certificates.
Activity Title: 2015
Activity Dates:
Activity Location:
Activity Medical Director:
Activity Coordinator:
1. CME Content Validation & Consistency
ATTESTATION: I attest that all education provided at this CME activity was: a) the same speakers & topics approved
by the Office of CME, b) within the scope of the Learning Objectives on the CME Credit Application for this activity,
c) evidence-based, d) free from promotion, and e) not biased by commercial interests.
Initials of Activity Medical Director
Initials of Activity Coordinator
2. Total Hours of CME provided through this Activity
Hours of CME
at each Meeting
X
Number of Meetings
(some CME activities meet more than once)
X
=
Total Hours of CME
=
3. Attendance - How many attendees will receive a CME credit certificate for this activity?
What was the Total Attendance for this activity?
The Total Attendance is the sum of all learners at all meetings (if applicable). For CME activities that only had one meeting/conference,
this is simply the number of people that attended. But for CME activities with multiple meetings/conferences, this is the sum of the
attendance totals from all meetings. For example, if the activity only met one time and had 20 attendees, then the Total Attendance is 1 x
20 = 20. But if the activity met twelve times and had 20 attendees at each meeting, then the Total Attendance is 12 x 20 = 240.
Of your Total Attendance, how many were physicians?
How many were non-physicians?
For CME activities that only had 1 meeting, only count each physician and non-physician once. For CME activities with multiple
meetings, count each physician and non-physician each time they attended. For example, if the same 10 physicians attended each of the 12
meetings at your CME activity, you should enter that 10 x 12 = 120 are physicians (even though there are actually only 10 physicians).
Required Attachment #1: An Attendance Report showing the first name, last name, degree, and number of hours
attended for each attendee receiving CME credit. The report needs to be an Excel spreadsheet. Click here or visit
www.utcomchatt.org/cme/closeout to download attendance report templates. Certificates for Non-Physicians:
We can issue certificates of attendance to non-physicians for their participation in this CME activity, and they can
obtain continuing education credits for attending activities that award AMA Category 1 CreditsTM. If the
Certificates will be Sent: Your Attendance Report also needs to include the OR the address, city, state, and
zipcode (if you want them mailed) for each attendee. CME Activities with Multiple Meetings: If your CME
activity had multiple meetings and you already closed-out the individual meetings, you do not need to provide
attendance reports again for those meetings. CME Credit for Speakers: Speakers may not receive CME credit
through this activity for giving a presentation at this activity, so your attendance report should not give your
speaker(s) credit for giving their presentation(s); this is because the ACCME considers “this learning from teaching”
as a separate learning activity from this CME activity; however, speakers can request CME credit directly from the
AMA for their CME talks.
ATTESTATION: I attest that the attendance report provided is accurate and commensurate with participation to the
best of my knowledge. I also attest that the attendance report does not give the speakers CME credit for giving their
talk(s) at this CME activity. Initials of Activity Medical Director or Activity Coordinator.
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4. Commercial Independence forms – All planners, speakers, and everyone else in a position to control the
planning, content, implementation, & evaluation of a CME activity must disclose all relevant financial relationships
with a commercial interest to the UT College of Medicine by completing a Commercial Independence form (per
page 7 of the CME Credit Application). (SCS: 2.1)
ATTESTATION: I attest that all individuals in a position to control the planning, content, implementation, &
evaluation of this activity completed a Commercial Independence form prior to the activity.
Initials of Activity Medical Director or Activity Coordinator:
5. Disclosures to Learners – Per the CME Credit Application (page 9), several pieces of information must be
disclosed to the learners at a CME activity: 1) the learning objectives, 2) the AMA Credit statement and
Accreditation statement, 3) the relevant financial relationships (or lack thereof) for all speakers and 4) any
commercial support received for this activity (if applicable).
ATTESTATION: I attest that this information was disclosed to the learners at this activity.
Initials of Activity Medical Director or Activity Coordinator:
6. Summary of the Evaluations – Evaluations are used to ensure that the audience did not perceive commercial bias
in the presentation(s) and as a source of feedback for the conference. You must summarize the responses received on
the evaluations for this CME activity.
Required Attachment #2: A summary of the responses received on your evaluations. Evaluation summaries can be
as simple as indicating the number of people that responded a certain way for each question or can include more
elaborate statistical analysis, but at a minimum the Summary of Evaluations needs to include (a) how many
evaluations were received and (b) either the average of the responses received for each question (expressed as a
percentage %) OR the number of people who responded each way. CME Activities with Multiple Meetings: If
your CME activity had multiple meetings and you already closed-out the individual meetings, you have already
satisfied this documentation requirement and do not need to provide anything for this attachment.
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7. Commercial Support – Commercial support is monetary or in-kind contributions received from a commercial
interest used to all or part of the costs of a CME activity. (A commercial interest is an entity that produces, markets,
re-sells, or distributes health care goods/services consumed by or used on patients.)
Exceptions by Organization Type: Hospitals and other providers of clinical service directly to patients are not
considered commercial interests.
Exceptions by Income Type: Commercial exhibits and advertisements are promotional activities and not continuing
medical education, so monies paid by commercial interests for these promotional activities are not considered
commercial support (ACCME).
Was commercial support received for this activity?
No, skip to the next page
Yes, fill out the information below:
Commercial Interest that provided
support: (organization name)
Amount (or Type) of
support received:
What part of this activity was the commercial
support used to support?
ATTESTATION: I attest that all commercial support received for this conference is disclosed above.
Initials of Activity Medical Director or Activity Coordinator:
Attachment #3, A Letter of Agreement is Required if commercial support was received: You must provide a letter of
agreement for each disbursement of commercial support that was (or will be) received for this CME activity. See page 9
of the CME Credit Application (click here or visit www.utcomchatt.org/cme/application) for more information about
letters of agreement for commercial support.
Required Attachment #3b, Required if the expenditure (use) of commercial support is not detailed in the letter of
agreement: You must provide documentation that details the expenditure/use of commercial support (i.e., what was the
money used for?) if it is not clearly indicated on the letter of agreement (SCS: 3.13).
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CLOSEOUT DOCUMENTATION CHECKLIST
The following documents *must be provided with closeout. Check the boxes to indicate attachments you have
already assembled so that you know which ones you still need as you prepare your closeout documentation.
Attachment #1: An Attendance Report for this activity. (see section 3, page 1)
Attachment #2: A Summary of the Evaluations for this activity. (see section 6, page 2)
*Exception for CME Activities with Multiple Meetings: If this CME activity had multiple meetings and you
already closed-out the individual meetings, then you do not need to provide the supporting attachments above.
Additional Attachments: Required if Commercial Support was Received
Attachment #3: A Letter of Agreement for each disbursement of Commercial Support (see section 7, page 3)
Attachment #3b: Documentation that details the expenditure of all Commercial Support received (see
section 8, page 3)
Visit www.utcomchatt.org/cme/closeout for templates and other resources for the required documentation.
CERTIFICATES OF ATTENDANCE FORMAT
How would you like us to issue the Certificates of Attendance for this CME activity?
Mail – the certificate will be mailed to each attendee.
Email – a PDF of all certificates will be emailed to the Activity Coordinator.
ATTESTATION & SIGNATURES
I attest that all information provided through this closeout form and the supporting documents is accurate and
complete to the best of my knowledge.
Signature of Activity Medical Director (typed or signed)
Date
Signature of Activity Coordinator (typed or signed)
Date
Have feedback about the CME process? We are always seeking to improve our process and services. Let
us know by sending an email to cme@erlanger.org
OFFICE USE ONLY
CME Closeout Approval – Reviewer:
Certificates – Created by:
Issued via:
In Mass, sent to:
Date Reviewed:
Delivery Method:
Email
/
/
Mail
Date Issued:
Individually, sent to each Physician
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