CME Activity Application Form
For additional guidance on completing this application, please contact AHEC for the Application Guide
1
Activity Title
Start Date
Start Time
Location
(Hotel, etc.)
City, State
End Date
End Time
Type of
Activity
Live Course (Conference, Symposium, Workshop,)
One-time event Multiple events (same course to be repeated during the year)
Internet Live (webinar):
Internet Activity, Enduring Material (describe):
Other (describe):
Physician Course Director:
Title:
Address:
Telephone:
Fax:
Email:
CME Activity Coordinator:
Title:
Address:
Telephone:
Fax:
Email:
2
Directly Sponsored: All Carolinas HealthCare System entities will be directly sponsored
Joint Providership: Non-Carolinas HealthCare System entities that are not independently accredited to provide CME will be joint providership .
List the organization(s) or entities involved in planning this activity below:
Co-Providership : Non- Carolinas HealthCare System entities that are independently accredited to provide
CME will be co-sponsored
List the organization(s) or entities involved in planning this activity below:
Organization Contact Name Phone #
3
Please check all that apply
Physicians (MDs, DOs)
Specialty(s) :
Physician Assistants/Nurse Practitioners
Nurses (RN,LPN, etc)
Estimate Attendance
Pharmacists
Other: Define
Other:
1 Reviewed: December 2013

CME Activity Application Form
For additional guidance on completing this application, please contact AHEC for the Application Guide
4
Please give a brief overview of the main goal or abstract of this activity as a whole:
5
Based on your main goal , what are the professional gaps/educational needs of the target audience that will be addressed? What about the current practice of these learners needs to change to achieve this goal?
How were those practice gaps identified? Check ALL that apply and ATTACH supporting documentation :
Expert Needs
Research findings
Institutional or national core measures
Required by Government Regulation/Law
Medical audits/ other patient care reviews
NCQA data / Quality committee recommendations
Current literature / Expert opinion/ New advances
Joint Commission Patient safety goal/ Competency
Other:
Participant Needs
Target Audience Needs Assessment Survey
Observed Needs
M&M data
Previously related Evaluations Summary Hospital admissions and diagnosis data
Professional/ ABMS requirements Data from outside sources/ Public health statistics
Requests from physicians or physician groups
Focus panel discussion /Interviews (provide summary)
Clinical practice data
Other:
Charlotte AHEC requires at least two examples of measured professional practice gaps (institutional, regional, or national) that have been identified by your department or practice. Below is a partial list of frequently used needs assessment sources.
2 Reviewed: December 2013

CME Activity Application Form
For additional guidance on completing this application, please contact AHEC for the Application Guide
Carolinas HealthCare System
Does this activity address any Carolinas HealthCare System 2013 Quality Goals?
Yes No N/A
Carolinas HealthCare System has identified the following core measures as areas for improvement for 2013.
CME activities that incorporate these goals will both improve compliance with these core measures, and provide valuable learning experiences for our attendees.
Carolinas HealthCare System Quality Goals 2013
Patient Safety : Patient Safety Composite, Agency for Healthcare Research and Quality (AHRQ), Patient Safety Culture Survey
Clinical Outcomes : Inpatient mortality, Appropriate care measures, Chronic disease mngt., Post-Acute care outcome measures
Service Excellence: Patient satisfaction, Physician satisfaction, Employee satisfaction
Clinical Efficiency : Acute care length of stay, Acute care inpatient re-admission, ED efficiency
6
Based on the gaps described in Section 5 , please relate the educational needs to the desired result you intend to achieve. The desired results should be based on best practices, best available scientific evidence, or evidence based clinical guidelines.
List at least 3 measurable, and specific objectives that the physician participants should be able to address and improve as a result of their participation in this activity as a whole. These objectives are to be stated in terms of what the participant should take away from the activity. See application guide for assistance.
(Best or evidence based practice)
Add more rows as needed
This objective will address the following level of desired outcomes:
Knowledge
Competence
Performance
Patient Outcomes
Knowledge
Competence
Performance
Patient Outcomes
Knowledge
Competence
Performance
Patient Outcomes
Knowledge
Competence
Performance
Patient Outcomes
Knowledge : acquiring facts and new information
Competence : knowing how to do something, the ability to apply knowledge, skills, and judgment in practice
Performance : what a physician or health care provider actually does in practice
Patient Outcomes : actual outcomes in individual patients and/or patient population data
3 Reviewed: December 2013

CME Activity Application Form
For additional guidance on completing this application, please contact AHEC for the Application Guide
7
CME activities should be developed in the context of desirable physician attributes. Please indicate which
American Board of Medical Specialties (ABMS)/Accreditation Council for Graduate medical Education
(ACGME) competencies will be addressed in this activity related to the identified gaps .
Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals
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
Professionalism , as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
Systems-Based Practice , as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value are that is of optimal value
8
Instructional Formats: (check all that apply)
What methods will you use to achieve your intended results ?
Lecture (knowledge) Self-Directed Learning (knowledge/competence)
Panel Discussion (knowledge/competence)
Roundtable (knowledge/competence)
Simulations (competence/performance)
Case Studies (Competence)
Q&A Session (knowledge/competence)
Small Group Work (knowledge/ competence)
Skilled demonstrations (competence/performance)
Other:
What educational strategies will be used that could enhance change in your learners as an adjunct to this activity? Examples include patient information packets, reminders, pocket guides, wall charts, resources, tool kits, protocols, links to social networks, interactive web-based tools, etc.
Explain:
Identified Barriers : What are the potential or real barriers that may prevent the learners from achieving the expected changes as a result of this activity?
Lack of Time to assess/counsel patients Lack of consensus on professional guidelines
Lack of administrative support/resources
Insurance/ Reimbursement issues
Patient compliance issues
Cost
No perceived barriers
Other:
4 Reviewed: December 2013

CME Activity Application Form
For additional guidance on completing this application, please contact AHEC for the Application Guide
Will you try to address any of these barriers in this CME activity? No Yes
Explain:
9
What changes to your activity do you intend to implement based on previous year s’ evaluation results? (If applicable)
How will you measure if changes in knowledge, competence, performance, or patient outcomes have occurred?
Charlotte AHEC CME activities must be evaluated in order to determine how effectively the course objectives were linked to the desired results, and Charlotte AHEC CME must review and approve your evaluation tool.
Evaluation method should match the level of desired outcomes selected in Section 6.
Measuring Knowledge/Competence
Post Program survey – required (Charlotte AHEC will conduct a follow-up survey 3-6 months following the program to assess the program's effectiveness in achieving desired outcomes)
Audience Response System
Customized Pre-and/or Post-tests
Measuring Competence
Pre and/or Post activity scenario-based questions
Learner reported intended practice change
Measuring Performance
New protocols or tools developed as a result of the educational activity
Small group work in practice redesign or quality initiative
Case based studies/ chart audits/ registry
Direct observations/hands-on simulations
Learner reported actual practice change
Other:
Measuring Patient Outcomes
Change in health status measure/outcomes data/ Quality data
5 Reviewed: December 2013

CME Activity Application Form
For additional guidance on completing this application, please contact AHEC for the Application Guide
10
List all Faculty and individuals involved with the planning and development of this course. Faculty, Physician
Course Director, CME Activity Coordinator, planning committee members and anyone else involved in the planning of the activity, or who could have control over the content, MUST complete and sign a Disclosure
Statement. All Disclosures for Planning Committee Members and the Physician Course Director MUST be submitted with this application.
Name Activity Role
Dr. Mary Hall , MD, FAAFP
Dr. Michael Ruhlen, MD, MHCM,
FAAP, FACHE
Carolyn Minnock
Review/Planning Committee: Deputy Chief Academic Officer, Senior Vice President-Division of
Medical Education
Review/Planning Committee: Vice President and Chief Medical Officer
Carolinas Medical Center - Pineville
Planning Committee: Director, Charlotte AHEC, CME & Pharmacy Education
The absence or existence of financial or other relevant relationships with commercial interests (see definition in Section 15 below or in the disclosure form) must be disclosed to the program participants before the presentation occurs. Disclosure may be made verbally and/or in writing.
11
Please attach a copy of the proposed activity schedule including time(s), topic(s), and speaker(s).
12
Charlotte AHEC’s offers many services such as event photography, webinar capabilities, AV equipment rental, setup, and/or operation by our audiovisual specialist staff. Please go to the following website to submit a request for service (The Medical Media team will contact you upon receiving your request via the website): http://www.charlotteahec.org/ahec_medical_media/ahec_audiovisual_photography/forms.cfm
Choose which service(s) you ’d like to use for this event.
Photography Audiovisual Staff
Audiovisual Equipment Rental Webinars
13
AMA PRA Category 1 Credit ™/ CEU
CNE (Nursing)
ACPE (Pharmacy)
Other, identify:
14
What revenue source(s) will pay for the expenses of the CME activity? (check all that apply).
Participant registration fees
Internal Department funds
6 Reviewed: December 2013

CME Activity Application Form
For additional guidance on completing this application, please contact AHEC for the Application Guide
Commercial support/exhibitor fees (complete #15 below)
Government or foundation grant
Other:
Please submit a copy of your proposed budget.
15
A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Commercial interests cannot be a joint providership.
The ACCME does not consider providers of clinical service directly to patients to be commercial interests.
Within the context of this definition and limitation, the ACCME considers the following types of organizations to be eligible for accreditation and free to control the content of CME:

501-C Non-profit organizations (Note, ACCME screens 501c organizations for eligibility. Those that advocate for commercial interests as a 501c organization are not eligible for accreditation in the
ACCME system. They cannot serve in the role of joint providership , but they can be a commercial supporter.)

Government organizations

Non-health care related companies

Liability insurance providers

Health insurance providers

Group medical practices

For-profit hospitals

For profit rehabilitation centers

For-profit nursing homes

Blood banks
Are you receiving educational grants?
Yes
If YES please describe entities:
Sponsors:
No
16
Physician (MD, DO): $
Interns/Residents: $
Mid-Level Providers (NP, PA): $
Other, identify: $
17
Please check all that apply
"Save the Date" (minimum 3 months prior)
Printed Brochure
Are you receiving exhibitor funding ?
Yes
If YES please describe entities:
Exhibitors:
No
AHEC Website
Website / URL:
7 Reviewed: December 2013

CME Activity Application Form
For additional guidance on completing this application, please contact AHEC for the Application Guide
Email/ E-postcard Other, identify:
Physician Connect (CHS Programs Only)
A copy of the promotional material(s) will be sent at least two months prior to the approved activity.
Charlotte AHEC MUST approve all promotional materials BEFORE they are distributed.
The Charlotte AHEC logo MUST be included on promotional material.
18
Fee MUST accompany the application prior to approval. If the activity application is denied, the $500 will not be returned or refunded. Invoices are available on request.
Check the method of payment:
Check attached
Carolinas HealthCare System Interdepartmental Transfer B/U#
Credit card
Department#
Visa Discover MasterCard American Express
Account # Expiration Date
Name exactly as it appears on the credit card:
Cardholder’s signature
Other:
8 Reviewed: December 2013

CME Activity Application Form
For additional guidance on completing this application, please contact AHEC for the Application Guide
19
Please type this application and submit the completed and signed copy by email to:
Carolyn Minnock, Director, CME & Pharmacy Education
Carolyn.Minnock@carolinashealthcare.org
Carolinas HealthCare System / Charlotte AHEC CME
Phone: (704) 512-7587
20
I, the Physician Course Director attests that he/she, as well as the CME Activity Coordinator, planning committee members, and faculty have been informed of the Charlotte AHEC CME Disclosure Policy (see attached Application Guide for additional details) and have agreed to comply with this policy.
I, the Physician Course Director, have read Charlotte AHEC's Policies and Procedures and the ACCME
Standards for Commercial Support of CME and understand the guidelines for management of commercial funds, if applicable.
I, the Physician Course Director will ensure the ‘Instructions from the Podium’ form is signed and returned to
Charlotte AHEC CME from each day of the activity.
Physician Course Director signature: Date:
APPROVED: DATE: __________________________ CME Director_______________________________
DID YOU FORGET SOMETHING?
ATTACHMENT CHECK LIST
Needs Assessment Documentation
Proposed Agenda and Budget
Disclosure Statements ( All Disclosures for Planning Committee Members and the Physician Course
Director MUST be submitted with this application.
)
A copy of the proposed activity announcement
** IN ORDER FOR YOUR PROGRAM TO BE IN COMPLIANCE, PLEASE REMEMBER TO
SUBMIT ALL MARKETING MATERIALS TO CHARLOTTE AHEC CME FOR APPROVAL
PRIOR TO DISTRIBUTION.
Typed and Signed Application emailed to Carolyn.Minnock@carolinashealthcare.org
9 Reviewed: December 2013