ASC CME Activity Planning Form
AMERICAN SOCIETY OF CYTOPATHOLOGY
CME ACTIVITY PLANNING FORM
This form is designed to facilitate the planning, implementation, and evaluation of a CME
activity that will comply with the Essential Areas and Standards of the ACCME. ACCME
Standards state that the CME provider (ASC) must use a planning process(es) that links
identified educational needs with a desired result in its provision of all CME activities. Please
refer to the ASC’s CME Mission Statement at the end of this form when you are planning your
activity.
Activity Date:
Activity Category:
 Breast
 Education/Training/Current Trends
 Fluids/CSF
 Genitourinary (Kidney/Bladder)
 Gynecologic
 FNA-General
 Head/Neck
 QA
 Lab Operations
 Soft Tissue/Bone
 Lung/Mediastinum
 Other
 Lymph Node/Hematopoietic
 Gastrointestinal Tract
 Pancreas/Liver
Presenter(s):
(Must be filled out for each speaker, as you want it to appear in print)
Full Name (First, MI, Last):
Credentials (degrees):
Job Title:
Institution Name:
Institution City:
Institution State:
(Preferred contact information and address for honorarium/reimbursement (as applies to ASC policy)
Email:
Phone #:
Address:
Address:
City:
State/Zip:
Target Audience:
 Novice
 Pathologist
 Student Cytotechnologist
 Local, Regional audience
 Intermediate
 Advanced
 Fellow/residents  Cytotechnologist
 Scientist
Others in the field of Cytopathology
 National/International audience
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ASC CME Activity Planning Form
Activity Title:
Upon conclusion of this presentation, participants will be able to…
Educational Objectives: (3 required)
Brief Abstract of the presentation (up to 50-100 words)
Professional Practice Gaps
State the professional practice gap(s) of your learners on which the activity was based.
(Why develop this activity?, Why address this topic?)
State the educational need(s) that you determined to be the cause of the professional
practice gap(s)?
(Why is there a need for this educational intervention?, How do you know that?)
State what this CME activity was designed to change in terms of learners competence or
performance or patient outcomes.
(What needs to change or improve to close the gap?, What is the reason the gap needs to be
addressed?)
Desired Results:
Clearly state the desired results that are expected once the participants have completed the
activity.
Which ACGME/ABMS competency areas are satisfied with this activity?
Each educational activity must be labeled with one or more MOC icons indicating the
competency area addressed in the Activity’s content. This will help develop an educational plan
that meets educational needs and builds knowledge/skills across the competency areas.
 PC MK  PB  IC PR  SB
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ASC CME Activity Planning Form
Patient Care that is compassionate, appropriate, and effective for the treatment of
health problems and the promotion of health, demonstrating a satisfactory level of
diagnostic competence and the ability to provide appropriate and effective
consultation in the context of pathology services.
Medical Knowledge about established and evolving biomedical, clinical, and cognate
(eg, epidemiological and social-behavioral) sciences and the application of this
knowledge to pathology.
Practice-Based Learning and Improvement that involves investigation and evaluation
of diagnostic and consultative practices, appraisal and assimilation of scientific
evidence, and improvements in patient care practices.
Interpersonal and Communication Skills that result in effective information exchange
and collaboration 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 pathology services that are of optimal
value.
Presentation Recordings (if session is confirmed for this):
As part of the Annual Meeting educational materials and as a service to participants, Electronic
Recordings of all presentations and the materials that I deliver to this Annual Meeting may be
made available to Annual Meeting participants and as post Annual Meeting materials made via
the ASC Web site as an archive, podcast, streaming Electronic Recording or a mobile
application. As a Annual Meeting speaker, I hereby consent to the recording, duplicating and
distribution of my presentation(s) and the material(s) that I deliver to this Annual Meeting via
an Electronic Recording and release, discharge and acquit the American Society of
Cytopathology from any and all claims, demands or causes of action that I may hereafter have
against the American Society of Cytopathology whether for libel or violation of privacy or
anything else by reason of recording, duplicating and distribution of my presentation(s) or the
material(s) that I delivered to this Annual Meeting via Electronic Recordings. This release form
in no way inhibits me from using my own materials in any manner I so desire.
____ Yes, I consent
____ No, I do not consent
Speaker Disclosure:
Please complete the speaker disclosure on the web site and sent to you (if applicable, either send it
to your panelists or advise me to send to them, upon receiving their contact information from you; I have ASC
member information).
Please visit the ASC Web site for important dates and details to come.
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ASC CME Activity Planning Form
Thank you for your time and expertise. The ASC greatly appreciates you participating in our
Annual Scientific Meeting.
Jodi Smith
ASC Educational Programs Coordinator
Please refer to the ASC CME Mission Statement when planning your CME activity.
1. Purpose
The Continuing Medical Education (CME) mission of the American Society of Cytopathology
(ASC) is to provide and support educational activities to encourage and promote greater
knowledge of cytopathology.
2. Content Areas
The content of the ASC CME program emphasizes enhanced detection, diagnosis and
prognostication and evaluation for targeted therapies of disease processes, and sets the highest
standards for quality patient care.
Additionally, the ASC CME program provides content for topics such as effective management
of pathology practice, medical ethics, risk management and other areas deemed relevant by
the needs of the membership.
3. Target Audience
The ASC is the premier national society in the country specifically addressing cytopathology.
The target audience for the ASC CME program is practicing pathologists, cytotechnologists,
trainees, scientists and others involved in the practice of cytopathology.
4. Types of Activities
General types of activities provided by the ASC CME program include, but not limited to, ,
lectures, workshops, seminars, annual conferences, webinars, and eLearning modules.
5. Expected Results
The expected results of the ASC CME are to encourage lifelong learning, self-assessment and
performance improvement with the goals of updating cytologists on current practice,
encouraging the highest quality in cytopathology, fostering research by cytologic methods and
providing a forum for advocacy on behalf of cytologists and their patients. Ongoing assessment
of the impact of the ASC CME program is important in determining modifications to existing
activities and the development of new activities. Example of changes the ASC expects to see as
a result of the CME program are, but not limited to, increased knowledge across the
cytopathology community, the refinement and application of new techniques or skills for the
improvement of practice and patient care.
Reviewed and approved by the ASC Executive Board, November 2013.
Continuing Medical Education (CME) *
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ASC CME Activity Planning Form
The American Society of Cytopathology is accredited by the Accreditation Council for
Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The American Society of Cytopathology designates this live educational activity for a maximum
of 52.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with
the extent of their participation in the activity.
American Board of Pathology Maintenance of Certification (MOC)
This product helps fulfill the requirements for Self-Assessment Modules (SAMs) mandated by
the American Board of Pathology Maintenance of Certification (MOC) process.
Continuing Medical Laboratory Education (CMLE)
The ASC designates these activities for the indicated number of Continuing Medical Laboratory
Education (CMLE) credit hours. The CMLE credit hours meet the continuing education
requirements for the ASCP Board of Registry Certification Maintenance Program.
This program is approved for continuing education credits in the State of Florida and in the
State of California (half the credit). The credit on each activity is good for three years from the
live presentation or release date.
To be completed by the Educational Planners:
ASC CME Activity # _________
Credit(s) offered:
 1.0
 CME (Category 1)
 2.0
 SAM
 Other _________
 CMLE
Type of CME Activity(ies):
 Annual Meeting
 Live Course
 PodCast/Archive/Recording
 Enduring Material
 eJournal
 Internet Enduring Material
 Case Study
 Regular Scheduled Series (RSS)
 Cyto-econference Series
 Internet Live
 Hot Topic
Other: _________________________________
What methods have been used to identify the gaps for this activity?
 ASC Education Survey of Target Audience
 ASC Educational Gaps/Needs Idea Box
 Previous CME Activity Evaluation Data
 Committee, Planner, Faculty Perception
 Consensus of Experts, Professional Colleagues  Commissioned Reports
 Reports Analyzing Weakest Areas of Self-Assessment  QA Data/Patient Care Audits
 ASC Social Media Discussions
 Review of Literature and Trends
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ASC CME Activity Planning Form
 Findings of ASC Task Forces/Workgroups
 ASC Listserv Discussions
 Call for Presentations & Abstracts Submissions  ASC Committee Charge & Discussion
 Other: ABP/MOC requirements, PEC Overall Data
Evaluation:
What methods will be used to determine if the desired results of this CME activity were met?
 Standard Evaluation Tool
 Pre-Test
 Post-Test
 3, 6 or 9-Month Follow-up
 Focus Group/Task Force
 Other: _____________________________________________________________________
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