CME Application/Planning Guide
(Rev. 6.2012)
PLANNER INFORMATION
CME Activity Director:
Phone:
Organization :
Fax:
Department:
Email
Address:
CONTACT PERSON
Name:
Phone:
Fax:
Email:
ACTIVITY INFORMATION
Title:
Code:
Location:
Start & End Dates:
Type of Activity:
Start & End Time:
Course
Enduring
Internet
Number of sessions offered:





Live
Regularly Scheduled Series (RSS)
Credits requested:
Directly Sponsored
Jointly Sponsored
All steps should be taken independently of commercial interests.
Everyone who is in a position to control content must disclose all relevant financial relationships with commercial interests to the provider.
Disclosure must be made to the learners of relevant financial relationships and any commercial support received for the activity.
The activity must promote improvements or quality in healthcare and not proprietary interests of a commercial supporter.
This application must be filled out entirely and ALL supporting documentation submitted to be considered for certification.
Date Rec’d: _______________
For CME Office Use Only
Approved by: _______________________
Approved for: ________ AMA PRA Category 1 Credit(s) ™.
Date Approved: ___________________
Course Code: ______________
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RSS Dates: _____________________
EDUCATIONAL PLANNING
1) Please describe the process used to plan this activity and ATTACH minutes from planning committee meetings:
2) Please list all planning committee members involved
in this educational activity and ATTACH a signed
disclosure statement for each:
2a)
Last Name, First Name, Degree
Please list all known speakers involved in
this educational activity and ATTACH a signed
disclosure statement for each:
Last Name, First Name, Degree
3) Who is the physician target audience for this educational activity?
4) What are the professional practice gaps/educational needs of the target audience that this activity will address? The “gap” is defined as the difference
between the current state of knowledge, skills, competence, practice or patient outcomes and the ideal or desirable state.
THE CURRENT STATE DESCRIBES PROBLEMS THE TARGET AUDIENCE OF PHYSICIANS FACE. (SAMPLE ON LAST PAGE)
Current state of knowledge, skills, competence, practice,
Desired/ideal state of knowledge, competence, performance,
clinical/patient outcomes that will be addressed.
clinical/patient outcomes.
1)
1)
2)
2)
3)
3)
2
5) How were these gaps/needs identified? Check those that apply and ATTACH supporting documentation.
DO NOT CHECK ITEMS FOR WHICH YOU CANNOT PROVIDE DOCUMENTATION
Planning committee meeting notes/minutes
Faculty communication
Previously related data/participant suggestions
Request from physicians
Increased prevalence/epidemic
Quality improvement guidelines
Clinical practice guidelines
Morbidity/mortality data
New technologies/procedures/treatments
Government legislation/mandates
Core measures
Other: (specify)
6) Based on the gaps/needs identified above, what are the learning objectives for this activity? SAMPLE ON LAST PAGE
Need: List the need of your own
Learning objectives should complete this
Outcome level addressed: This learning objective represents a
learners that corresponds to a
sentence: As a result of participating in this
change in:
learning objective
activity participants should be able to:
1)
1)
Competence
Performance
Patient Outcomes
2)
2)
Competence
Performance
Patient Outcomes
3)
3)
Competence
Performance
Patient Outcomes
4)
5)
4)
5)
Competence
Competence
Performance
Performance
Patient Outcomes
Patient Outcomes
7) Briefly explain the use(s) for this activity based on the gap(s) identified above (1-2 sentences per gap): SAMPLE ON LAST PAGE
8) The content of this activity has been planned to address the learning objectives.
Yes
No
9) What ACGME (Accreditation Council for Graduate Medical Education), ABMS (American Board of Medical Specialties), IOM (Institute of Medicine) desired physician attributes are
associated with this activity?
Provide patient centered care
Interpersonal and communication skills
Utilize informatics
Medical knowledge
Practice-based learning and improvement
Systems based practice
Work in interdisciplinary teams
Apply quality improvement
Professional standing
Employ evidence based practice
Professionalism
Commitment to lifelong learning
10) The educational format(s) that best support the objectives of the activity:
Lectures
Hands on-Skills Session
Internet/Webcast
Q&A / Discussions
Video/Audio
Case Presentations
Panel Discussion
Other: (specify)
3
11) What are the QA and/or PI initiatives associated with this activity?
12) Will commercial support be sought?
No
If yes, list all potential supporters below:
Name of Company
Yes
12a) Will vendor exhibits be present?
No
If yes, list names of vendors below:
Name of Exhibitor
NOTE: A Letter of Agreement must be signed by the supporter and the
OCME PRIOR to the date of the event.
Yes
NOTE: Please submit a copy of the registration form from each
vendor.
13) How do you plan to evaluate the activity to determine its effectiveness at meeting the needs and creating change in competence, performance, or
patient outcomes? Please ATTACH your evaluation tool.
ARS
Standard paper evaluation
Post-test
Post course follow-up
Focus group
Survey
14) How will you promote your activity?
Flyer/brochure
Emails
Practice data
Chart review
Other: (specify)
ATTACH a draft copy and submit to the OCME for approval.
Website
Conference Calendar
Other: (specify)
15) ATTACH a proposed budget on the form included in your packet.
DOCUMENTATION CHECKLIST:
Completed Application/Planning Guide
Planning minutes
Proposed budget
Exhibitor forms, if applicable
Planner disclosures
Practice gaps/needs supporting docs
Draft copy of flyer/brochure
Director Agreement, signed
Speaker disclosures
Evaluation tool
Letter of Agreement, if applicable
Signature of Activity Director __
_______________________________ Date signed __
4
______
SAMPLE #4
4) What are the professional practice gaps/educational needs of the target audience that this educational activity will address? The “gap” is
defined as the difference between the current state of knowledge, skills, competence, practice or patient outcomes and the ideal or desirable state.
THE CURRENT STATE DESCRIBES PROBLEMS THE TARGET AUDIENCE OF PHYSICIANS PRESENTLY FACES.
Desired/ideal state of knowledge, competence, performance,
Current state of knowledge, skills, competence, practice,
clinical/patient outcomes.
clinical/patient outcomes.
.
1) HIV providers and patients are faced with a constantly evolving
1) Increased knowledge of current HIV treatment guidelines.
2) Increase ability to correctly diagnose older patients with HIV.
standard of care. This poses a challenge for assuring that HIV
3)
treatment is consistent with the most current guidelines.
2) Misdiagnosis often occurs in older women due to HIV symptoms
being similar to those associated with aging.
3)
SAMPLE #6
6) Based on the gaps/needs identified above, what are the learning objectives for this activity?
Need:
1) Our physician HIV providers need
educational initiatives related to
current HIV treatment guidelines.
2) Our physician HIV providers need
educational initiatives to help them
better identify HIV risk behaviors and
symptoms in women over 50.
Learning objectives: As a result of
participating in this activity participants should
be able to:
Outcome level addressed: This learning objective represents a
change in:
1) Describe current HIV treatment guidelines.
Competence
Performance
Patient Outcomes
2) Recognize HIV risk behaviors and symptoms
of HIV infection in women over age 50.
Competence
Performance
Patient Outcomes
3)
3)
Competence
Performance
Patient Outcomes
4)
4)
Competence
Performance
Patient Outcomes
5)
Competence
Performance
Patient Outcomes
5)
SAMPLE #7
7) Briefly explain the use(s) for this activity based on the gap(s) identified above (1-2 sentences per gap): By training through lecture, videos and case
studies HIV providers will have a better understanding of the latest HIV treatment guidelines. Learners will walk away better equipped to identify risk
behaviors in general, but in particular, risk behaviors associated with women over the age of 50. The ability to identify, diagnose and chose appropriate
treatment plans for the HIV patient will translate into improved patient care..
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