Word Document - Continuing Medical Education

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					             CERTIFICATION APPLICATION FOR AMA PRA Category 1 Credit™
                        REGULARLY SCHEDULED SESSIONS (RSS)


Title of CME activity:

Sponsoring Department/Division:

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:       _______                 ___

Email:                                                             Phone:


Who is the staff person primarily responsible for the operational and administrative support of the certified activity?


Departmental Contact Person:                                                              Title:

Dept./Division/Campus address:

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
    __ Fellows
    __ Residents
    __ Medical Students
    __ Other Health Sciences Students
    __ Nurses
    __ Allied Health Professionals
    __ Community Physicians
    __ Other


    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)

          1)
          2)
          3)
          4)
          5)



    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.

        1)
        2)
        3)
        4)
        5)



    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.)

     __ Lectures
     __ 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
     __ Other


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.

    Knowledge/Competence
    __ Survey or evaluation form collected from participants
    __ Customized pre/post-tests designed for this educational activity
    __ Other ________________________________

    Performance
    __ Adherence to guidelines
    __ Chart audits
    __ Case-based evaluations
    __ Direct observations
    __ Custom designed focus groups, interviews
    __ Other ________________________________

    Patient/Population Health
    __ 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

         1)
         2)
         3)
         4)
         5)



    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.
VI. Acknowledgement

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:




                                                                                                          Updated: 06/22/10

				
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