CME APPLICATION AND PLANNING GUIDE
                                                                                                     FOR A Formal CME Event
                                                                                                    New or Annual Conference

   A Formal CME activity is considered to be one that is presented as a live conference or lecture and is usually intended for an external audience.

START DATE                                                                   END DATE
START TIME                                                                   END TIME
(Hotel or other, etc.)

                                         SPONSORSHIP AND COURSE MANAGEMENT

JOINT                          YES If yes, please complete the Joint Sponsorship Agreement and include it
SPONSOR(S)                  with this application. List the organization(s) or outside entities involved in planning
Organizations or            this activity below.
entities outside of          ORGANIZATION                 CONTACT NAME                PHONE #
GBMC HealthCare
who are not accredited
by the ACCME
Agreement                   Is a member of GBMC Medicine Faculty involved in the planning and/or organization of
                            this activity?
                                YES        NO If yes, Faculty member’s name:
Course Director                                                CME Liason
Planner                                                        Title
Title                                                          Address/City/St
Address/City/St                                                Telephone
Telephone                                                      Fax
Fax                                                            Email

                                                   PLANNING INFORMATION
TYPE OF ACTIVITY                          Formal Activity (symposium, course, conference)     Short Activity or lecture
                                      1-2 hrs.)
                                          Series (same content presented multiple times)
                                          NEW REQUEST                              ANNUAL ACTIVITY
DESIRED CREDITS                           AMA Category 1               Credits for other          If other credits applied
                                                                  disciplines will be applied for, please list
Note: The CME Office is not responsible for the application and execution of credits for any other disciplines. All
responsibility for these credits falls under sponsoring department

FORMAL APPLICATION FORM                                                      1                                                     6/2007
     The ACCME requires the following decisions in planning a CME activity be made free of control of a
     commercial interest. These decisions include:
            1) Identification of needs, 2) determination of objectives, 3) selection of presentation of content,
            4) selection of personnel and organizations who would be in a position to control the content,
            6) selection of educational methodology, and 7) evaluation of the activity
     Refer to the Standards for Commercial Support of Continuing Medical Education
2.   PLANNING PROCESS              Describe the planning process.
                                   List below all individuals who involved in planning.
                                   Name                         Affiliation                           Disclosure
                                                                                                      Forms are

                                All planners must complete GBMC’s Resolution of Personal Conflicts of
                                Interst form. The forms MUST accompany this application. Refer to
                                section on Disclosure further in the application.
3.   PURPOSE                    What is the intended overall purpose for this activity?

4.   TARGET AUDIENCE               Physicians
     Check all that apply.         Specialties (specify):
                                   Physician Assistants
                                   Health care administrators
                                   Allied health professionals (specify):
                                   Local           State      Regional       National       International
                                Estimated Attendance: Physicians               Other
5.   NEEDS ASSESSMENT              Evaluation from previous CME activities or survey results (e.g., attach past
     ACCME Requires             evaluation summary or survey results with relevant suggestions highlighted)
     Documentation                 Expert opinion, faculty expertise, or advice from experts (e.g., attach
     Supporting documents       minutes, notes, relevant publications, or bibliographies)
     MUST be included with         Data from internal or external sources such as NIH or public health
     the application. Check     agencies (e.g., attach relevant reports, articles, mandates, state/national
     all methods that apply.    surveys, or other such documents)
                                   New medical technology (e.g., articles, reports, etc.)
                                   Research findings (e.g., attach relevant research reports or journal articles)
                                   Literature reviews (e.g., attach journal articles, internet searches, medical
                                data base search information, etc.)
                                   Hospital admissions and diagnosis data
                                   Medical Audits/Quality Assurance information (e.g., attach QA
                                minutes/reports, input from Physician Review Organizations)
                                   Formal or informal requests from physicians, please explain:           (e.g.,
                                notes from conversations, survey results, etc.)
                                   Other, please explain:
     NEEDS ASSESSMENT           Summary:
     In a brief SUMMARY
     paragraph describe
     specific needs that were

FORMAL APPLICATION FORM                                  2                                        6/2007
6.    OBJECTIVES                 Based on what you hope to accomplish, list three or four things that you
      REQUIRED BY THE            would like for the participants to be able to do as a result of participation
      ACCME                      in this activity. Attach a separate page if necessary.
      The audience must be       Terminology for educational objectives usually begins with, "Following this
      provided information       activity, the participant should be able to . . ." followed by phrases that
      about the activity’s       communicate a performance capability by the participant, verbs such as:
      goals and/or objectives    describe, analyze, discuss, compare, differentiate, examine, formulate,
      before activity occurs.    propose, evaluate, assess, measure, select, and choose. If additional space is
                                 required, please submit educational objectives as an attachment.

7.    EVALUATION                 Participants should have the opportunity to 1) assess the extent that the
      ACCME Requirement          objectives were met, 2) rate the quality of instruction; 3) rate the extent that
      All CME activities MUST    their professional effectiveness will be enhanced; 4) confirm that disclosures
      be evaluated to            were made known to the audience at the beginning of the activity; and 5)
      determine its              confirm that commercial support was acknowledged.
      effectiveness of meeting   What method(s) will be used to assess what the participants have
      the identified             learned as a result of attending this educational activity?
      educational needs.            Course evaluation immediately following the activity using the CME’s
                                 Office’s standard form.
                                 And (may select another type if desired)
                                    Other type of evaluation form (attach a copy).
                                    Post-conference survey (attach a copy).
                                    Other (attach a copy) Or, describe
8.    EDUCATIONAL                What instructional methods will be
      FORMAT                     used?
                                 (Check all that apply)               Live demonstration of procedure
                                    Lecture/didactic                  Video demo. of procedure
                                    Panel discussions                 Skills workshop
                                    Case studies                      Other, please describe.
                                    Interactive workshops
9.    FACULTY                    How and by whom were the speakers selected?
10.   ACTIVITY AGENDA            A copy of the proposed schedule is attached.       Yes       No
                                 If no, please explain.

      List below faculty/speaker/moderator/author (name, title, and affiliation). Attach a separate page, if
       Speaker/Moderator/Author        Academic/Professional Titles        Institution or           Disclosures
                                                                           Affiliation              Attached

      Please attach a copy of a curriculum vitae or biological sketch for each course faculty

FORMAL APPLICATION FORM                                   3                                         6/2007
11.   DISCLOSURE OF           GBMC Disclosure Policy
      FINANCIAL               It is the policy of GBMC HealthCare to ensure balance, independence,
      RELATIONSHIPS           objectivity, and scientific rigor in all of its educational activities. In
      REQUIRED BY THE ACCME   accordance with other policy, all individuals who are in a position to
                              control the content of the educational activity are required to disclose all
                              relevant financial relationships he/she has with any commercial
                              interest(s). These individuals include course/activity directors, planning
                              committee members, staff, teachers, or authors of CME. The ACCME
                              defines relevant financial relationships as those in any amount occurring
                              within the past 12 months that create a conflict of interest. Individuals
                              who refuse to disclose will be disqualified from participation in the
                              development, management, presentation, or evaluation of the CME
                              Everyone involved in planning and content development for a CME
                              activity must be informed about the disclosure requirements.
                              How were planners and faculty informed about disclosure?
                              Attach copies of letters, memos, emails, etc.
                              Refer to sample letter or faculty memo
12.   DISCLOSURE FORMS and          The “Disclosure of Relevant Financial Relationships” (disclosure
      RESOLUTION OF                    form) is the mechanism used by the CME Office to gather
      CONFLICTS OF INTEREST            information about relevant disclosures.
      (COI)                         This form must be completed by EVERYONE who has the
                                       opportunity to influence the content of the CME activity speakers,
                                       authors, moderators, etc.
                                    Individuals refusing to disclose MUST NOT be allowed to
                                       participate in the CME activity
                                    It is the responsibility of the Course Director to make certain that
                                       all of the disclosure forms are collected, reviewed, and submitted
                                       to the CME Office well before the activity begins.

13.   PROVIDE DISCLOSURE TO   How will the audience be given disclosure information?
      PARTICIPANTS            Written:       Handouts            Slides        Other, describe.
                                 A copy must be included in the Activity Closing Report.
                              Verbal:        Speaker             Moderator
                                 A Verbal Disclosure Attestation Form must be completed and
                              included in the Activity Closing Report.
14.   COMMERCIAL SUPPORT      Will this activity receive support from
      REQUIRED BY THE ACCME   Educational grants?           Yes         No
                              1) Letters of Agreement for Commercial Support (LOA) obtained for
                                  ALL educational grants. They must be signed by both the company’s
                                  representative and the CME Coordinator.
                              2) The LOAs or copies must be sent with this application form or with
                                  the activity closing report.
                              Exhibit fees?                 Yes         No
                              The audience must be informed about commercial support.
                              How will commercial support for this activity be acknowledged?
                                  Brochures         Handouts/syllabus      Verbally    Other, please
                              Management of Commercial Support
                              The Course Director and CME Associate have read the ACCME’s
                              Standards for Commercial Support of CME and understand the
                              guidelines for management of commercial funds.          Yes       No

FORMAL APPLICATION FORM                          4                                        6/2007
15.   MARKETING AND                        How will notification of this educational activity be distributed to the
      ADVERTISING                          participants prior to the activity?
      The ACCME requires certain
      information be included on                Brochure
      promotional materials - the               Email
      objectives, faculty, correct              Website: URL site:
      sponsorship, accreditation                Fax
      and credit designation                    Other, identify:
      statements. The CME Office
      must approve promotional                We would like the CME Office to arrange for marketing
      materials before they are               A copy of the promotional material is attached.
      printed.                                A copy of the promotional material will be sent later for approval.
16.   BUDGET INFORMATION                   How will activity expenses be paid? (check all that apply)
      Attach a preliminary budget             Internal department funds
      (rough estimates are                    Participant registration fees
      acceptable) including all               Commercial Support
      projected revenue and                   State or Federal Grant
      expenses. A final income and            Other, identify:
      expense report is required
      with the activity closing report.

Approval Signatures:
This program was planned in compliance with the Essentials of CME, the ACCME Guidelines of Commercial Support and
the AMA "Ethical Opinion on Gifts to Physicians." The content, objectives and design of the program are solely for
educational purposes and were planned by a committee representing GBMC. All profits from this program will be
reimbursed to the assigned budget and that budget will also reimburse the CME Department for any loss.

_________________________                                           ____________________
Program Director                                                          Date

I agree with the needs assessment, target audience, conference goal, objectives, instructional method, publicity and budget. I
have reviewed the content of this program and assure departmental support of this activity.

_________________________                                           ____________________
Chairman's Signature                                                Date

This program has been reviewed and meets the Essentials for planning a CME activity. This program is approved for
Category 1 credits.

_________________________                                           ____________________
CME Coordinator’s Signature                                         Date

_________________________                                           ____________________
CME Director’s Signature                                                  Date

FORMAL APPLICATION FORM                                         5                                            6/2007
                            not approved
                                missing information    does not meet Category 1 criteria     other
    For CME Office use:
                          If approved,
                             Paperwork sent to Department      entered into Excel
                            entered into MeetingTrak

FORMAL APPLICATION FORM                       6                                     6/2007

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