Vanderbilt University School of Medicine
DIVISION OF CONTINUING MEDICAL EDUCATION
Application Submission Checklist
Persons requesting CME credit from the Vanderbilt Division of CME must follow these procedures:
Step 1. Register in the VCME Learning Management System

CME Associate sets up User Profile
Step 2. Submit application materials prior to activity start date



Departmentally managed activities: all materials should be submitted at least six months in advance of the
activity start date. Credit will not be awarded if applications are submitted less than three months prior to the
activity start date.
Jointly sponsored activities: all materials must be submitted at least six months in advance of the activity start
date.
Regularly scheduled series (RSS): all materials should be submitted at least three months in advance of the
activity start date. Credit will not be awarded if applications are submitted less than one month prior to the
activity start date.
All activities:

Application form including signed cover sheet

Documentation for performance gap

Completed/signed Disclosure of Financial Relationships form for each Course Director and (content) Planner

Preliminary schedule or agenda

Preliminary budget

Evaluation form
Recurring departmentally managed and jointly sponsored activities only:

Close-out of previous activity
Jointly sponsored activities only:

Partnership agreement
Step 3. Review CME and ACCME guidelines



Read Overview of VCME Policies and Procedures
Course Director and Vanderbilt CME Director meet to discuss content of application
CME Associate participates in VCME training
Vanderbilt CME, Application for Sponsorship and Credit Designation of a CME Activity, page 2
Vanderbilt University School of Medicine
DIVISION OF CONTINUING MEDICAL EDUCATION
Application for Sponsorship and Credit Designation of a CME Activity
Title of CME Activity
Sponsoring Department
Date, Day, Time
Location
Course Director
CME Associate
VU SOM Academic Rank
Title
Telephone
Telephone
Fax
Fax
Email
Email
VCME Asst. Director
Nanette Bahlinger
VCME Administrator
Telephone
615-322-0672
Telephone
Fax
615-322-4526
Fax
Email
nanette.bahlinger@vanderbilt.edu
To be completed by VCME
Email
Submission
1.
The information on this form is the result of educational and administrative planning associated with offering this CME activity.
2.
I have reviewed the “Disclosure of Financial relationships” form for the planners of this CME activity and determined that
there are no conflicts of interest between the financial relationship(s) that were disclosed and the content of this CME activity.
3.
I understand that it is my responsibility to review the presentations of speakers who indicate that they have financial
relationships with companies that make products or services related to the content of their presentations.
Course Director
Date
Approval
1.
I approve the sponsorship of this CME activity by my department or division.
2.
I accept financial responsibility on behalf of my department/division for the direct and indirect expenses of this CME activity
3.
I have reviewed the “Disclosure of Financial Relationships” form for the course director and determined that there are no
conflicts of interest between the financial relationship(s) that were disclosed and the content of this CME activity.
Chair/Chief
Approved for
Date
_____
AMA PRA Category 1 Credits
Director, Division of CME:
_________________________________________
Fee:
________
Date:
________
CME Application 2011
Vanderbilt CME, Application for Sponsorship and Credit Designation of a CME Activity, page 3
1.
List below individuals who are involved in planning the content of this CME activity.
Name
Institution
Role
Course Director
Planner
Planner
Planner
Planner
Each individual listed above may be able to influence the content of this CME activity. ACCME requires that each of
these individual disclose financial relationships related to the content of this CME activity. To meet this requirement,
each individual must complete the Vanderbilt CME form, “Disclosure of Financial Relationships.”
2.
1.
The completed forms for each individuals listed above must accompany this application.
2.
The “Disclosure of Financial Relationships” forms for each individual listed above must be reviewed, approved,
and signed by the course director prior to the submission of this request.
3.
The “Disclosure of Financial Relationships” form for the course director must be reviewed, approved, and signed
by the division chief or department chair prior to the submission of this request.
What type of educational activity are you planning? (Select one)

Performance improvement

Internet searching and learning

Live course

Enduring material, internet: archived webcast

Live regularly scheduled series

Enduring material, other: print, CD, DVD

Live internet: video conference, webcast

Manuscript review

Test item writing

Journal CME
3.
Describe the target audience for this CME activity. Include information about physician specialties, other health
professions, and geographic area.
4.
What type of results do you hope to accomplish by offering the CME activity you are planning? (Select only one.)

Competence
Physicians should be able to describe a new or improved strategy that applies to the content in clinical
practice or demonstrates application of the content in a simulated practice environment or educational
setting. Go to item #5.

Performance
Physicians actually apply the content of this CME activity in their practice settings.
Skip item #5; go to item #6
CME Application 2011
Vanderbilt CME, Application for Sponsorship and Credit Designation of a CME Activity, page 4
5.
Describe how you will plan and evaluate this educational activity to achieve the desired results of improved
COMPETENCE by responding to the items below. This question consists of six parts (a-f), each of which must be
answered.
Competence means that physicians should be able to
1)
describe a new or improved strategy that applies the content in clinical practice
2)
demonstrate application of the content in a simulated practice environment or educational setting
a.
Please describe the current competence(ies) that you want to improve and/or the new competence(ies) that you
want to develop by offering this CME activity.
b.
Please state the educational need that must be addressed before the current competence(ies) can be improved
or new competence(ies) can be addressed. Your educational need statement should describe a gap between the
current level of knowledge, skills, and attitudes, and the level of knowledge, skills, and attitudes necessary for
competence(ies) to be improved or new competence(ies) to be developed.
c.
Where did you obtain information about current and desired levels?
Desired
Levels
Current
Levels
Questionnaire before CME activity


Summary of results
Case scenario(s) before CME activity


Summary of results
Peer-reviewed journal article


Abstract(s) attached
Expert opinion


Written summary from the expert(s)
Interview/focus group


Summary
Request by target audience


Summary
Quality improvement data


Summary
Practice guideline/clinical pathway


Table of contents or executive summary
Other, _____________________________


Method:
d.
Example of expected documentation:
Based on the results that you want to accomplish, state three or more things that you would like physician
participants to be able to do after they participate in this CME activity. (Learning objectives)
After participating in this CME activity, participants should be able to describe and discuss:
1)
2)
3)
CME Application 2011
Vanderbilt CME, Application for Sponsorship and Credit Designation of a CME Activity, page 5
e.
To accomplish your goal of improving current competence(ies) or developing new competence(ies), the
educational activity that you are planning should include the following educational strategies. Please indicate if
you will be using these strategies and the specific technique that you will be using.




f.
Physician participants are provided with opportunities to hear information related to the competence(ies) to be
improved and/or developed.

Lectures

Panel presentations

Readings distributed before the CME activity

Other:
Physician participants are provided with opportunities to hear and/or see examples of the improved and/or new
competence(ies) in practice settings.

Case presentations

Skill/technique demonstration

Other:
During the CME activity, physician participants are provided an opportunity to practice the competence(ies) that
they learned.

Case discussion

Case discussion with audience response system (ARS)

Skills lab

Animal lab

Other:
During the CME activity, physician participants are provided feedback on the competence(ies) that they
demonstrated.

ARS results and discussion

One on one discussion

Group discussion

Other:
How do you intend to determine whether or not physician participants have improved current competence(ies) or
developed new competence(ies)? (Evaluation)

self-report questionnaire after the CME activity (CME will provide a template.)

self-report questionnaire before and after the CME activity

commitment to change after the CME activity

commitment to change after the CME activity and follow-up

self-report questionnaire using case scenarios after the CME activity

self-report questionnaire using case scenarios before and after the CME activity

observation by faculty during the CME activity

other, please specify:
A proposed evaluation form that assesses physician competence must accompany this application.
SKIP TO ITEM #7
CME Application 2011
Vanderbilt CME, Application for Sponsorship and Credit Designation of a CME Activity, page 6
6.
Describe how you will plan and evaluate this educational activity to achieve the desired results of improved
PERFORMANCE by responding to the items below. This question consists of six parts (a-f), each of which must be
answered.
Performance means that physicians actually apply the content of this CME activity in their practice settings
a.
Please describe the performance in practice that you would expect to see as a result of offering this CME activity.
b.
Please state the educational need that must be addressed before the expected performance in practice can be
demonstrated. Your educational need statement should describe a gap between the current level of knowledge,
skills, and attitudes as well as competence, and the level of knowledge, skills, and attitudes as well as
competence necessary for the expected performance in practice to result.
c.
Where did you obtain information about current and desired levels?
Desired
Levels
Current
Levels
Questionnaire before CME activity


Summary of results
Case scenario(s) before CME activity


Summary of results
Peer-reviewed journal article


Abstract(s) attached
Expert opinion


Written summary from the expert(s)
Interview/focus group


Summary
Request by target audience


Summary
Quality improvement data


Summary
Practice guideline/clinical pathway


Table of contents or executive summary
Other, _____________________________


Method:
d.
Example of expected documentation:
Based on the results that you want to accomplish, state three or more things that you would like physician
participants to be able to do after they participate in this CME activity. (Learning objectives)
After participating in this CME activity, participants should be able to:
1)
2)
3)
CME Application 2011
Vanderbilt CME, Application for Sponsorship and Credit Designation of a CME Activity, page 7
e.
To accomplish your goal of improving current competence(ies) or developing new competence(ies), the
educational activity that you are planning should include the following educational strategies. Please indicate if
you will be using these strategies and the specific technique that you will be using.




f.
Physician participants are provided with opportunities to hear information related to the competence(ies) to be
improved and/or developed.

Lectures

Panel presentations

Readings distributed before the CME activity

Other:
Physician participants are provided with opportunities to hear and/or see examples of the improved and/or new
competence(ies) in practice settings.

Case presentations

Skill/technique demonstration

Other:
During the CME activity, physician participants are provided an opportunity to practice the competence(ies) that
they learned.

Case discussion with ARS

Skills lab

Animal lab

Simulation

Other:
During the CME activity, physician participants are provided feedback on the competence(ies) that they
demonstrated.

ARS results and discussion

One on one discussion

Group discussion

Other:
How do you intend to determine whether or not physician participants have improved current competence(ies) or
developed new competence(ies)? (Evaluation)

self-report questionnaire after the CME activity (CME will provide a template.)

self-report questionnaire before and after the CME activity

commitment to change after the CME activity

commitment to change after the CME activity and follow-up

self-report questionnaire using case scenarios after the CME activity

self-report questionnaire using case scenarios before and after the CME activity

observation by faculty during the CME activity

other, please specify:
A proposed evaluation form that assesses physician performance must accompany this application.
CME Application 2011
Vanderbilt CME, Application for Sponsorship and Credit Designation of a CME Activity, page 8
7.
Identify the desirable physician attributes (ABMS/ACGME Core Competencies) that will be addressed by this CME
activity.

8.
Patient 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 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 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, 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
Identify the speaker(s), panelists , moderators, etc, and tell us their institutional affiliation and academic title.
Name
Institution
Academic Title
Anyone in a position to influence the educational content of your CME activity is required by the ACCME to complete
and sign a “Disclosure of Financial Relationships” form. This includes, but is not limited to course directors, content
planners, speakers, panelists, moderators, discussants, authors, and editors. “Disclosure of Financial Relationships”
forms must be submitted to the Division of CME for review at least four weeks before the CME activity begins.
CME Application 2011
Vanderbilt CME, Application for Sponsorship and Credit Designation of a CME Activity, page 9
9. Please provide financial information in the budget format below:

No direct costs associated with this CME activity; no budget is prepared
REVENUE
BUDGETED
ACTUAL
BUDGETED
ACTUAL
BUDGETED
ACTUAL
TOTAL EXPENSES (DIRECT + INDIRECT)
BUDGETED
ACTUAL
DIFFERENCE (TOTAL REVENUE – TOTAL EXPENSES)
BUDGETED
ACTUAL
Registration Fees
Refunds
Commercial Support (Educational Grants)
With your final (actual) budget, attach a separate sheet with grants
itemized; list company names and amounts.
Exhibit Fees
Other Revenue, Please specify source:
TOTAL REVENUE
DIRECT EXPENSES
Speaker Expenses
Speaker Fees (detailed listing required on following page)
Staff Expenses
Recruitment Expenses (brochure, etc.)
Food and Beverage Service
Facilities
Course Materials
Audio-visual
Other Expenses, Specify:
TOTAL DIRECT EXPENSES
INDIRECT EXPENSES
CME Fee
IDS Tax
Other Indirect Costs, Specify:
TOTAL INDIRECT EXPENSES
Please note:
1.
Financial information for this CME activity in this budget format must accompany this request for credit.
2.
The budget must be approved by the Division of CME before this request for credit can be approved.
3.
A financial summary using the same format must be submitted after the CME activity.
CME Application 2011
Vanderbilt CME, Application for Sponsorship and Credit Designation of a CME Activity, page 10
9. (continued)
Please list all speakers, panelists, or moderators who will be receiving a speaker’s fee (honorarium) and the amount of the fee,
and all speakers whose expenses related to their participation in this CME activity will be reimbursed.
Vanderbilt CME policy on speaker fees limits what speakers can be paid. See the table of the bottom of this page. If you wish
to request an exception from the policy, please place “” in the column labeled “Request Exception” and insert the number that
reflects your reason from the list at the bottom of the page in the far column to the right.
Speaker
Expenses
Amount
Speaker Fee
Amount
(See Below.)
Request
Exception
No
Yes
Reason for
Request
Select from
list at bottom
of page.
Vanderbilt CME Speaker Fee policy
1.
2.
Policy recommended range for speaker fee: $500 to $2,500.
Policy recommendation that Vanderbilt faculty not receive speaker fee.
Reasons to request an exception to Speaker Fee policy:
1.
2.
3.
One of the very few people who can address this topic.
Speaker is involved in multiple presentations, panels, workshops in this CME activity.
Significant time away from Vanderbilt practice
4.
Other, _______________________________________________
CME Application 2011
Vanderbilt CME, Application for Sponsorship and Credit Designation of a CME Activity, page 11
10. Will this CME activity receive commercial support (educational grants)?

No

Yes
Please provide the information requested below. Use a separate sheet if more than five companies.
NOTE: Effective July 1, 2009, “The Division of Continuing Medical Education should be informed at the time of submission
of requests for grants to support educational events. Agreements governing grants supporting educational events must
receive prior approval by the Division of Continuing Medical Education.”
NOTE: Effective July 1, 2009, grants for CME-certified activities must be made payable to and processed by the Vanderbilt
Division of CME.
Company
Amount Requested
A fully executed Letter of Agreement (LOA) for each grant received must be submitted to the Division of
Continuing Medical Education before the CME activity begins. At a minimum, the following terms will be agreed to:
1. The accredited sponsor is ultimately responsible for control of content and selection of presenters, moderators, etc.
2. The accredited sponsor will disclose funding sources and faculty financial relationships to the audience
3. The accredited sponsor will ensure that the CME activity provides a balanced view of therapeutic options and
does not promote or unfavorably present the product or service of a pharmaceutical or medical device company
4. The accredited sponsor will require that presenters or moderators in the CME offering disclose when a product is
not approved in the United States for the use under discussion.
5. The accredited sponsor will require accurate documentation detailing the receipt and expenditure of commercial
support
11. Will there be exhibitors at this CME activity?

No

Yes
Please provide the information requested below. Use a separate sheet if more than five companies.
NOTE: Effective July 1, 2009, “Promotional items which incorporate or display a product or company logo of a Health Care
Industry entity must not be used or displayed on the VUMC campus. This prohibition shall include exhibitions by industry
representative at, or adjacent to, certified CME activities.”
NOTE: Effective July 1, 2009, marketing/sales representatives will be prohibited from attending educational events
sponsored by Vanderbilt.
Company
Amount Requested
A copy of the Vanderbilt CME form “Agreement to Exhibit” for each exhibit participating, signed by a company
representative must be submitted to the Division of Continuing Medical Education before the CME activity begins.
12. How will disclosures be made to the audience? (Select all that apply)
Speaker &
Planner
Financial
Relationships
Commercial
Support/No
Commercial
Support




N/A



In materials distributed to participants as part of the course syllabus/handout
At the beginning of each speaker’s slide presentation
On the sign-in sheet (RSS only)
At the beginning of this enduring material, internet CME, or journal CME
Documentation that the selected disclosure(s) occurred must be provided with close-out materials.
CME Application 2011
Vanderbilt CME, Application for Sponsorship and Credit Designation of a CME Activity, page 12
13. Is there a registration fee for this CME activity?
 no

yes
Amount for MDs:
Amount for other health professionals:
Amount for non VUMC residents:
Amount for non VU SOM medical students:
14. Do you plan to reduce or waive registration fees?

Not applicable; no registration fee

no

yes
VU SOM medical students

No fee

Fee equal to variable costs
Department residents

No fee

Fee equal to variable costs
Department physicians

No fee

Fee equal to variable costs
Department staff

No fee

Fee equal to variable costs
Fraud and abuse regulations restrict the individuals or groups to whom reduced or waived registration fees can be
offered. Reducing or waiving registration fees can be perceived as an attempt to influence referrals to Vanderbilt
physicians.
15. How will participants be recruited to register for this CME activity? Check all that apply.
NOTE: Communication about CME activities sponsored by Vanderbilt School of Medicine must come from the
institution or joint sponsor; representatives of pharmaceutical companies and medical device manufacturers, for
example, are not allowed to recruit for CME activities.

Direct mail “Mark Your Calendar”/”Save-the Date” announcement to target audience

Direct mail brochure or flyer to target audience

Email “Mark Your Calendar”/”Save-the Date” announcement to target audience

Email brochure or flyer to target audience

Announcement about your CME activity on the Department/Division web page

“Mark Your Calendar”/”Save-the Date” announcement on a partner’s web page

Announcement about your CME activity on a partner’s web page

Letter from course director to select group of target audience

Purchased journal advertising

Purchased web advertising

Other
There are requirements for any recruitment materials that mention AMA PRA category 1 credit. This material must
be reviewed and approved by the Division of CME before it can be distributed to potential participants.
16. Are you applying for other types of credit in addition to AMA PRA Category 1 credit?

No

Yes (please indicate which types of credit below)

AAFP (American Academy of Family Physicians)

ACOG (American College of Obstetricians and Gynecologists)

AOA (American Osteopathic Association)

APA (American Psychological Association)

other, please specify:
Please provide the Division of CME with a copy of your approval letter from AAFP, ACOG, AOA, or APA, if applicable.
CME Application 2011