RCPSC SECTION 1 ACCREDITATION
APPLICATION FORM
Please complete this form in Microsoft Word and return – with supporting documentation.
 Electronic submission is preferred. 
Title of Rounds/Journal Club/Program:
Planning Committee/Rounds Chair Name:
Email:
Phone:
Date of application:
I am applying for accreditation of a (select one):
Rounds series
Journal Club series
Small Group Learning Activity
Other (describe):
NB: This form can not be used for accreditation of clinical conferences, workshops, seminars, or annual research days. These
events must be reviewed and approved by an accredited provider such as the Faculty of Medicine’s Office of Continuing Education &
Professional Development. Please see www.cepd.utoronto.ca for more information. If you are unsure if this form is applicable to
your program, please call us at 416-978-4499 or email christian.base@utoronto.ca with a description of your educational sessions,
their frequency, and duration.
Divisional assignment of program (check one):
Clinical Pharmacology
Critical Care Medicine
Emergency Medicine
Endocrinology & Metabolism
General Internal Medicine
Geriatric Medicine
Immunology
Infectious Disease
Nephrology
Neurology
Physiatry
Respirology
None of the above – Specify:
Cardiology
Dermatology
Gastroenterology
Haematology
Medical Oncology
Occupational Medicine
Rheumatology
Target audience:
Whose continuing professional development (CPD) goals and objectives are you trying to fulfill? Only list those who are part of your
target audience and not others who may attend for their own interest only. Be specific – e.g. Neurology residents; academic
Cardiologists; community-based Dermatologists; nurse practitioners; physical therapists; etc.
Planning committee:
The Royal College of Physicians and Surgeons of Canada requires that the “planning committee members must be representative of
their intended target audience to ensure CPD goals and objectives are relevant and reflected in the scope of the events planned by
the committee.”1 Therefore this includes any trainee, community, and interprofessional groups you identified in your target audience
above.
UofT Faculty of Medicine Members
Name
Target Audience Representation
Institutional affiliation/Community
Integrated Medical Education Site or other Community Members
Name
Target Audience Representation
Institutional affiliation/Community
Trainee Members
Name
Target Audience Representation
Institutional affiliation/Community
Other Members
Name
Target Audience Representation
Institutional affiliation/Community
Host institution:
Other participating/affiliated institutions:
Approximate number of participants:
1
http://rcpsc.medical.org/opa/moc-accreditation/self-accreditation/planning-committee_e.php, accessed June 24, 2010.
Scheduling and location of rounds/sessions:
e.g. Thursdays, 1pm, 1 hour, Sunnybrook McLaughlin Auditorium, EG61; or Second Wednesday of each month, 1.5 hrs, Mount Sinai
11th Floor Classroom
Learning Needs Assessment:
In order to develop activities that facilitate learning, it is essential that the planning committee implement a needs assessment strategy
to enable the identification of the target audience's perceived and unperceived learning needs. By determining these needs, the
planning committee will be able to establish general and event specific learning objectives to ensure that selected topics are relevant to
the target audience.
Required: A summary of a learning needs assessment completed within 6 months prior to your date of application must be
attached. Applications without a learning needs assessment summary will be returned without being reviewed.
For tips on learning assessment methods, see tinyurl.com/CEPD-Needs.
Subjective data
Personal requests
Personal observations
Questionnaires/survey
Focus groups
Comments on evaluation forms
Objective data
Literature surveys/reviews
Referral/consultation
Other, e.g. ICES data
Practice data
Experience
Educational Goals, Learning Objectives, and Learning Methods
Goals: Describe overall learner performance changes or
Learning Objectives: Describe specific changes in
patient outcome changes your program aims to achieve:
e.g. Keep arthritis health care professionals updated on the
diagnosis and management of rheumatological conditions
behavioural terms:
e.g. Participants will be able to apply recent advances in arthritis
treatments in their practice
1.
2.
3.
1.
2.
3.
Learning formats that will be used to support learning objectives:
e.g. Seminars, lectures, PBL (problem-based learning), simulations, debates,…
Interactive learning methods:
List interactive methods that will be used to make each session at least 25% interactive. For tips see tinyurl.com/CEPD-Learning.
e.g.
Learning reinforcement methods/Practice reminders, enablers or Practice Tools:
Comment on the possible use of reinforcement methods to help change practice. For tips see tinyurl.com/CEPD-enablers.
Evaluation & Feedback
Attach a copy of the evaluation form to be used or indicate if you will use the Department of Medicine
evaluation form
Own evaluation form
U. of T. DOM form
Other method of evaluation:
(describe)
Does the evaluation method measure for perception of commercial bias?
Yes
No
Does evaluation method measure clinical practice behaviour change?
Yes
No
Describe how speakers will receive feedback on their teaching (Note: U. of T. Dept. of Medicine faculty will
automatically receive quantitative feedback if evaluated with the Departmental evaluation form)
Scholarship
Have you considered ways these events could result in scholarly work?
If yes, describe. / If no, why not?
Yes
No
Funding/Sponsorship
Will your rounds receive any external funding or sponsorship?
Yes

Single funding source /
Multiple funding source
 Describe funding source(s):
 Describe measures to prevent any perception of bias:
No
Attendance Record Keeping
Person responsible for record keeping and attendance confirmation on request:
The Planning Committee is responsible for keeping records of attendance and providing confirmation of attendance on request
Name:
Phone:
Email:
Fax:
Chair’s Declaration
As Chair of the planning committee, I will ensure that the educational activities offered as Accredited
Group Learning Activities meet all the requirements (educational and ethical standards) for the
Maintenance of Certification program. These events will adhere to the Canadian Medical Association
Guidelines governing the relationship between physicians and the pharmaceutical industry which I can
review on the Royal College of Physicians and Surgeons of Canada website at
rcpsc.medical.edu/publications/index.php. Upon request I will provide participants proof of attendance.
I Agree
I disagree
Chair’s Name:
Director’s Approval
(Office use only)
As the Director, Continuing Education and Knowledge Translation & Exchange for the Department of
Medicine, I approve this application for accreditation under Section 1 of the RCPSC framework for
Maintenance of Certification:
Director’s Signature:
Mary J. Bell
Comments:
Date:
Please return to:
Email: christian.base@utoronto.ca
 Electronic submission is preferred. 
If necessary, hard copies can be sent to:
Accreditation, Office of CE & KTE
Department of Medicine, University of Toronto
3S805 – 200 Elizabeth Street
Toronto, ON M5G 2C4
Phone: 416-978-4499 / Fax: (416) 978-7230