CERTIFICATION APPLICATION FOR AMA PRA Category 1 Credit™
REGULARLY SCHEDULED SESSIONS (RSS)
Title of CME activity:
Check one: __ Renewal of existing program __ New application
I. Activity Information:
Please provide the following:
a. Frequency: Usual location:
(weekly, monthly, or quarterly)
b. Day and time: Duration:
c. Estimated attendance: ____
d. Is this activity appropriate for non-faculty physicians? __ Yes __ No
Briefly describe this proposed educational activity in 3-4 sentences.
Who is primarily responsible for planning, developing, conducting, and evaluating this CME activity on an ongoing
basis? (Note: this is usually a physician or faculty member). If co-hosted with another Division or Department, list
name(s) of other individual responsible for planning the activity.
Course Director: Title:
Dept/Division/Campus address: _______ ___
Who is the staff person primarily responsible for the operational and administrative support of the certified activity?
Departmental Contact Person: Title:
Email: Phone: Fax:
Is there a planning committee (other than those listed above) responsible for determining the content for this activity?
__ Yes __ No If yes, please provide the following information:
Name Title Dept/Affiliation Email
Members of the planning committee listed above must complete the UAB Disclosure Statement for managing conflicts of
interest in CME activities certified for AMA PRA Category 1 Credit
II. Educational Planning and Design – ACCME Essential Area 2 Elements 2.1; 2.2; 2.3; 3.3
Who is the target audience for this certified activity? (Please check all that apply)
__ Departmental Faculty
__ Medical Students
__ Other Health Sciences Students
__ Allied Health Professionals
__ Community Physicians
What are the educational needs of the target audience that are addressed by this activity? Please identify 3-5
educational needs and them below: See handout on needs assessment. (e.g., gaps in knowledge or skills)
How were those learning needs identified by your department/division? (Please check all that apply)
__ Literature review
__ Ongoing census of diagnoses made by the physicians on your staff
__ Survey of target audience by use of questionnaire or interviews
__ Input from experts and authorities in the field
__ Previous CME activity evaluation data
__ Periodic discussions in departmental meetings
__ Data from outside sources (public health statistics)
__ Other methods used or additional explanation: ___
Documentation for each source of information identified above must accompany this application.
Identify 3-5 learning objectives you hope to achieve through this CME activity. Your objectives should logically
follow from the identified educational needs. Objectives may relate to knowledge, competence, or performance and
may include changes in problem solving, attitudinal changes, or improved understanding of complex relationships.
Example 1: “Following these conferences, participants will be better able to discuss new treatment modalities and
indications”. Example 2: “Following these conferences, participants will improve the quality of their physician-patient
communication”. See handout on learning objectives.
How will these objectives be communicated to the audience? (Examples include flyers, announcements, etc.).
How is this CME activity structured (type of education format) to achieve these overall learning objectives?
(Please check all that apply.)
__ Case studies
__ Journal club
__ Panel discussion
__ Hands-on practicum, lab or simulation
__ Bedside rounds or similar observation and discussion of patients
__ Interactive workshop
__ Video presentation
III. Evaluation and Outcomes – ACCME Essential Area 3 Element 2.4
How will you measure if changes in knowledge, competence, performance, or patient outcomes have occurred? Check
next to each learning outcome below that apply to your CME activity. Competence is defined as the ability to apply
knowledge, skills, and judgment in practice (knowing how to do something). Performance is defined as what one actual
does, in practice.
__ Survey or evaluation form collected from participants
__ Customized pre/post-tests designed for this educational activity
__ Other ________________________________
__ Adherence to guidelines
__ Chart audits
__ Case-based evaluations
__ Direct observations
__ Custom designed focus groups, interviews
__ Other ________________________________
__ Observe changes in health status measures
__ Observe changes in quality measures and cost of care
__ Patient feedback and surveys
__ Observe changes in mortality/morbidity rates
__ Other _________________________________
Please note that you will be asked to provide summary data for the evaluation method you select and
evidence of the outcomes you checked above.
IV. Financial Disclosure – ACCME Standards for Commercial Support Standards 1-3
It is important to note that financial disclosure of each planner and presenter is required, even if the RSS activity
does not receive commercial support. All individuals in a position to control course content of this CME activity must
disclosure any relationship with a commercial interest that benefits the individual or a member of their family in any
financial amount and has occurred within the past 12 months
How will you communicate both planner and presenter disclosure to participants at each conference? (REQUIRED—
MUST CHECK AT LEAST ONE)
__ In writing as a hand-out to the participants
__ By announcement when planners and presenters are introduced
__ As a slide before the presenter speaks
NOTE: Documentation of all financial disclosures must be maintained by your office to demonstrate that appropriate
financial disclosures have been communicated to the audience(s) for your RSS event.
V. Commercial Support & Letters of Agreement (LOA) – ACCME CS Standards 1-3
The University of Alabama School of Medicine is committed to offering continuing medical education
activities that promote improvements in healthcare delivery and quality, and are independent of influence
from commercial interests. In order to comply with University policy, a fully-executed Letter of Agreement
must be completed prior to the beginning of the activity. Please review the March 2009 Guidelines for
Relationships with Industry document, the ACCME Standards for Commercial Support document, and the
UAB CME commercial support flowchart for more information.
Do you plan to seek or apply for commercial support for this educational activity?
__ No __ Yes
Please provide additional information below if you plan to seek commercial support for your educational activity.
Company name Amount requested
What form will this financial support take? __ money __ services __ food
How will the support be provided?
__ On a program-by-program basis
__ In support of a series of programs
__ Other: ___________________________________
How will the commercial support relationship be disclosed to the audience?
A fully executed copy of a Letter of Agreement for each grant anticipated must be in the CME activity files before the
CME activity begins. Without a completed LOA on file, CME certification of your activity may be revoked.
NOTE: After the activity, you will be required to provide CME with a budget showing how the commercial support was used.
I understand and agree to the terms set out in this agreement for AMA PRA Category 1 Credit™. I further acknowledge
having received and reviewed the UAB CME Policies and Procedures (June 2008) document and other supportive
documentation that accompanied this application.
Course Director Signature: Date:
Following a review of this application, a letter will be sent to the primary planner indicating the certification decision and
describing required next steps. The Division of CME will work closely with your department to assist you in complying
with the Essential Areas and Standards of the Accreditation Council for Continuing Medical Education in the conduct of
these certified CME credit activities.
FOR CME OFFICE USE ONLY
Application complete? Yes No
If no, describe disposition:
Action: Approve Reject
If approved, Course Code Assigned _____________
If rejected, describe reasons:
Application Fee Received? Yes No How verified?___________________________
Reviewer’s name: ________________________________ _____ Date of review :
Approval signature: ________________________________ _____ Date of approval: