(v.3) 9-14-15
Enduring Materials
CME Program Application
“Please Note: Throughout this document, endnotes are used to provide you with additional
information or examples. If you are using Microsoft Word 2010 (or below), you can hover your
mouse over the footnote number and you will see the information you are seeking in a pop-up.
Otherwise, you still have access to the same information, but you will have to scroll to the end of
the document to find the supplemental information in the actual endnote.”
Information available to person completing the application:
 Instructions:i
 Deadlines:ii
o Caution related to the months the Board does not meetiii
o Enduring Materials activities for which Educational Grants are being soughtiv
 Contact Informationv
Type of Activity
1. What type of activity are you
proposing?
Printed, recorded or computer-presented
activity.
Internet-based activity.
Other, please describe.
Activity Information
2. Proposed Activity Name:
3. Brief description of proposed activityvi
4. Proposed release date:
5. Proposed termination date:
6. What ETSU department is planning
this activity?
7. Has this activity previously been
approved by ETSU Office of CME?
No
Yes.
As what?
A Live Activity
As an previous Enduring Material Activity
Documenting the Need
8. What leads you to believe this
education is needed
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
(v.3) 9-14-15
9. What data do you have that supports
this need?
10. How will this educational activity
address this need? (Check all that
apply)
11. All Continuing Medical Education is
required to contribute to physician
competency. The following is a list of
ABMS/ACGME Physician
Competencies. Please check those
that would be addressed in this
activity.
Requests by participants in previous health
activities
Organizational mandate or new initiative
Emerging clinical guidelines or new technology
Focused discussion with the physicians who
would potentially attend the seminar
Quality improvement or performance data
Primary research on physicians in the targeted
communities
Other. Please explain:
It will impart:
Knowledge: No activity will be approved that
provides ONLY knowledge. While the activity can
impart knowledge, it must also address
Competency or Performance
Competency: The activity provides knowledge
AND the process, strategy, or tools to apply that
knowledgevii
Performance: The activity arises out of
performance or quality improvement data,
examines current clinical practice performance
and measures it against established guidelines,
newly developed or adopted performance
standards, or previous performance data viii
Patient careix
Practice-based learning and improvementx
Interpersonal and communication skillsxi
Professionalismxii
Medical knowledgexiii
Systems-based practicexiv
Learning Objectives
12. What will you look for (in competency,
performance or patient outcomes)
that will indicate this activity has been
successful?
13. Please translate these desired
outcomes into 2-5 learning objectives
for the activity:
(For assistance in crafting your
objectives, hover you mouse over a
2
There probably can only be one answer here . . . and
that is the competency outcome as measured in pre
and post tests!
As a result of participating in this activity, the
attendee should be able to…….
1
2
3
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
(v.3) 9-14-15
footnote number to view examples of
verbs that convey “Knowledge”xv ,
“Comprehension”xvi, “Analysis”xvii,
“Ability to Evaluate”xviii,
“Application”xix “Skill
demonstration”xx)
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Target Audience
14. Who is your intended physician
audience?
Family Physicians
Internal Medicine Physicians
OB/GYN Physicians
Pediatricians
Psychiatrists
Surgeons
Emergency Medicine Physicians
Other Specialists – Please List:
15. Who is your intended non-physician
audience?
Advanced Practice Nurses
Physician Assistants
Pharmacists
Psychologists
Nurses
Medical or Nursing Students
Other Specialists – Please List:
Unique Enduring Materials Requirements and Accountabilities
16. Anticipated time for participant to
complete the learning activity
17. What type of medium or combination
of media do you envision being
included?
3
Interactive internet module
CD based activity
Archived Webcast
PowerPoint Slides
PDF
Archived Streaming Video
Text with graphics
Audio
MP3 or Podcast
Recorded Teleconference
Audio CD
Audio Tape
Other: Please describe:
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
(v.3) 9-14-15
18. What equipment is required for the
learner to participate in the
educational activity?
Please list all the faculty involved in this
activity along with their credentials
19. What will the principal faculty
develop? Which of the following
components of the enduring material
will the faculty develop?
Content
PowerPoint
Audio
Video
Interactive web pages
20. Please describe what you anticipate
will be the role of CME planner, if any,
in the development of these materials.
Principal Faculty Information
21. NamePrincipal
Facultyxxi
22. Title/Credentials
23. Specialty
24. Organization Name / College /
Department
25. Address
26. E-mail Address
27. Phone
Planning Committee
Name and Title
Specialty
Phone Number
E-mail Address
Contact Information (If different from Principal Faculty)
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
(v.3) 9-14-15
Contact Person Name
Title
Organization
Address
Phone Number
Fax Number
E-Mail
Next Steps
You may call the Office of Continuing Medical Education during business hours to receive assistance with completing this
application, or to discuss anything related to your potential activity. Our number is 423-439-8081.
Save this only as a Word document, and return this form (In its electronic version) via e-mail to dougherty@etsu.edu.
Within a few days one of our educational planners will give you a call.
Required Attachments
1) You must provide the following documents with your application:
a) A “Required Signatures Form” that has imbedded in it the Principal Faculty’s Conflict of Interest Disclosure and
his or her signature accepting responsibility for the program. Click this link to access this form: Required
Signature Form
b) The Principal Faculty’s CV
c)
A copy of any data you may have that demonstrates the need for this program, as addressed in Question 12.
2) Additional documents required before the Advisory Board Meeting (1st Thursday of each month) are:
a) A “Conflict of Interest Disclosure” completed by each member of the Planning Committee. This takes no more
than 1 minute, and can be accomplished by sending this link to each member of the planning committee:
http://com.etsu.edu/esurvey/Survey.aspx?surveyid=1405
b) The CV of each member of the Planning Committee
3) All required attachments can be sent by fax or scanned and inserted into for email. Our fax number is 423 439
8040. Our application e-mail address is dougherty@etsu.edu.
Person
Principal Faculty
CV
Conflict of
Interest
Disclosure
X
Required
Signature
Form
X
Contact Person
Planning Committee
Members
Department Chair or
5
X
X
X
X
Comments
Principal Faculty’s COI disclosure is
embedded in the Required Signature Form
CV and Conflict of Interest Disclosure
required of Contact Person only if they
participate on the planning committee.
Send COI link to all members of the planning
committee: Planning Committee Member
Conflict of Interest Disclosure Statement
X
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
(v.3) 9-14-15
Healthcare Executive
Instructions:
Send to
CME via
fax or email
Send this
link to all
planning
committee
members
Planning
Committee
Member
Conflict of
Interest
Disclosure
Statement
To obtain
form, follow
this link
Required
Signature
Form
Contact information
Phone Number: 423-439-8081
Fax Number: 423 439 8040
E-mail address for applications and
attachments: dougherty@etsu.edu
Send
completed
form to CME
via fax or email
End of document
Footnotes
i
Instructions:
 This application is in MS Word, and is a form. To complete, put your cursor in a grey shadowed area and start
typing. It is difficult to spell check in a Word Form, so be aware that this is not a problem to us if your spelling is not
perfect. If you are the person completing this application, it is important that you have significant information on
the need, focus and expected outcomes of the proposed activity.
 If this is the first time you have completed one of our applications, we do not expect you to complete this
application flawlessly. However, you must complete it thoughtfully. Once we have received it, our planners will
assist you in further refining your application until it is ready for the Advisory Board’s review. This consultation
process is what makes it necessary for the application to be submitted according to the deadlines.
 You may contact us at any time if you need clarification on the application or the process.
 Once the application is complete, you may either e-mail (preferred) or fax it to the Office of Continuing Medical
Education. The contact information is listed at the end of the application.
ii
Deadlines:
All applications and their supporting documentation receive a thorough internal review before they are submitted
to the Advisory Board. Deadlines are set to accommodate that internal review, and to provide the best opportunity
for the activity to be approved.
 Advisory Board meetings are the first week of the month. Applications for live conferences must be received by the
first day of the month that PRECEEDS submission to the Advisory Board. For example, an application that is going to
be reviewed by the board the first week of May must be submitted to the Office of Continuing Medical Education by
April 1.

iii
The Advisory Board does not meet in January or July. Applications which would ordinarily be submitted for January or
July review, will need to be reviewed at the December or June meetings respectively. This shortens your application
deadline by an additional month. Contact us by phone if you are caught by this unawares.
iv
Add an additional 90 days of planning time to the above application deadlines if your organization would like
assistance in securing educational grants to support the program. Please note that NO commercial support can be
requested or received by any party to the activity except the Office of Continuing Medical Education.
v
Office of Continuing Medical Education
James H. Quillen College of Medicine
East Tennessee State University
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
(v.3) 9-14-15
Box 70572
Johnson City, TN 37614-1708
Phone: 423-439-8081
Fax: 423-439-8040
Email: dougherty@etsu.edu
Website: http://www.etsu.edu/com/cme/
Example: A 2 hour web module utilizing computer-assisted learning with a built in pre test/post test on blood
management for oncologists, pathologists, and surgical specialists.
vi
vii
Competency: Examples of activities that achieve competency are those that have a skill or knowledge achievement
that is measured by testing or observation (Such as ACLS, NCC Certification Testing). Other examples of competency
related activities are those in which the participant leaves the series with tools, e.g. flow diagrams, clinical guidelines, or
chart forms which he/she can incorporate immediately in clinical practice, thus implementing the newly acquired
knowledge.
OUTCOME MEASUREMENT OF COMPETENCY includes pretest/post test, case presentation with audience Q & A and self
reported changes in practice, measured after the fact.
viii
Performance: Activities include those in which QI or process improvement is used to identify a problem, a change is
identified and implemented, and the same process is used to identify the (+/-) change in the practice performance or
patient outcomes. Examples include activities where physicians, in conjunction with a healthcare organization, and
based on some QI, sentinel event, or other objective data, examine the appropriateness of their clinical practice
guidelines, study the evidence as to the best guidelines to choose or incorporate into practice, educate the medical staff
on the newly established guidelines, and re-measure the same data or performance after the guidelines have been
implemented.
Another example is when a physician audits his/her own practice against established evidence based guidelines for a
specific patient population, making a change in process or policy, and after a time, re-auditing the practice against the
same guidelines. The performance outcome is achieved when the later audit is measured against (+/-) the previous one.
OUTCOME MEASUREMENT OF PERFORMANCE includes objective data such as percent of change in practice
performance or patient outcomes measured over time.
ix
Patient care that is compassionate, appropriate, and effective for the treatment of health.
x
Practice-based learning and improvement involves investigation and evaluation of their own patient care, appraisal
and assimilation of scientific evidence, and improvement in patient care.
xi
Interpersonal and communication skill results in effective information exchange and teaming with patients, their
families, and other health professionals.
xii
Professionalism is manifest by commitment to carryout professional responsibilities, adherence to ethical principles,
and sensitivity to a diverse patient population.
xiii
Medical knowledge demonstrates established and evolving biomedical, clinical and cognate (e.g., epidemiological and
social-behavioral) sciences and the application of this knowledge to patient care.
xiv
System-based practice is manifest by actions that demonstrate an awareness of and responsiveness to the larger
context and system for health care and the ability to effectively call on system resources to provide care that is of
optimal value.
xv
Verbs that inform: Cite, Define, Describe, Identify, List, Name, Recite, Record, Recognize, Select, State, Summarize,
Update, Write
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
(v.3) 9-14-15
xvi
Verbs that denote comprehension: assess, associate, classify, compare, contrast, demonstrate, describe,
differentiate, distinguish, estimate, explain, locate, identify, interpret, predict, report, review
xvii
Verbs that indicate analysis: analyze, appraise, contrast, criticize, detect, differentiate, distinguish, evaluate, infer,
measure, question, summarize
xviii
Verbs used to evaluate: assess, choose, compare, critique, decide, determine, estimate, evaluate, measure, rate,
recommend, select
xix
Verbs that demonstrate application: apply, calculate, choose, demonstrate, develop, examine, illustrate, interpret,
locate, operate, practice, predict, report, review, select, treat, use, utilize
xx
Verbs that demonstrate skills: demonstrate, diagnose, integrate, manage, measure, operate, perform, record
xxi
The Principal Faculty must be a physician or nurse practitioner. The Principal Faculty must have direct involvement in
the planning of the activity, and will need to be in a position to collaborate with the Office of Continuing Medical
Education as the planning unfolds.
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education