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Joint Sponsorship Application - JOINT SPONSORSHIP

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Joint Sponsorship Application - JOINT SPONSORSHIP Powered By Docstoc
					                                         JOINT SPONSORSHIP
                           AMA CATEGORY 1 CREDIT APPLICATION
                    UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE
                       OFFICE OF CONTINUING MEDICAL EDUCATION
                Only applications with complete information will be accepted. Please type

1. DEPARTMENT or ORGANIZATION

   ADDRESS

   CITY            STATE                   ZIP

   PHONE               FAX                 EMAIL

2. NAME OF PERSON COMPLETING THE APPLICATION:

3. PROGRAM TITLE

4. DATE OF PROGRAM

5. PROGRAM LOCATION:

6. REGISTRATION FEE:

7. WHAT WILL BE THE EDUCATIONAL DESIGN OF THE ACTIVITY?

           Lecture and Questions                        Panel Discussion
           Seminar/Small Group Discussion                  Case Presentation & Discussion
           Interactive lecture with audience response
           Other - Please describe:


8. FACULTY DISCLOSURE Please review the attached Conflict of Interest Policies.
   Disclosure must be made of any significant financial interest or other relationship a faculty member,
   program planner, or the sponsor has with the manufacturer(s) of any commercial product(s) discussed in an
   educational presentation. You also need to disclose if the faculty or planner has no financial interest or
   other relationship.

   Each presenter and planner must complete a Disclosure Form, and all forms must be submitted with this
   application.

   You will need to give the disclosure information to the audience in writing for each speaker and planner.
   This can be done in your program announcement or in a written Disclosure Summary given to the
   participants at the activity.

   SAMPLE DISCLOSURE STATEMENT
          UNM CME policy, in compliance with the ACCME Standards of Commercial Support, requires that
   anyone who is in a position to control the content of an activity disclose all relevant financial relationships
   they have had within the last 12 months with any commercial interest.
                                                                                                      Rev. 12/ 17/09
   The following planners and faculty of Current Concepts in General Surgery disclose that they have no relevant
   financial relationships with any commercial interest.

   Drs. A,B,C

   The planners and faculty of Current Concepts in General Surgery listed below have disclosed that they have a relevant
   financial relationship with a commercial interest. The relationships were reviewed by UNM CME and the planning
   committee, and conflicts of interest were resolved prior to the activity.

   Name                         Commercial Interest                Relationship
   Dr. John Doe                 Pfizer                             Speakers Bureau, Research Grant


       If there is a conflict of inte rest, the following steps will be taken to resolve the conflict:

       1. The person responsible for the event will discuss the conflict with faculty prior to their presentation(s); i.e., if
          the speaker is including a name brand in his/her presentation, they must include two additional brands in their
          presentation.
       2. The person responsible for the event will review the faculty presentation(s) prior to their presentation(s).
       3. The person responsible for the event will complete an evaluation form on each presentation for those speakers
          that disclosed a conflict of interest.


9. EVALUATION
   Please attach a copy of your course evaluation form. We would be happy to work with you to design an
   appropriate evaluation form.

   The evaluation form must assess:
          a. The extent to which educational objectives are met
          b. The quality of the instructional process
          c. The participants’ perception of enhanced professional effectiveness
          d. The evidence presented for clinical recommendations
          e. Any commercial bias conveyed by the presentation(s).




10. COMMERCIAL SUPPORT:

       Will the conference be supported by funds from the manufacturer of drugs, devices or services? (Exhibits are
       not considered commercial support)
             No            Yes     If yes, please list the company(s) below:
       Commercial Support should be in the form of a Grant to the organizer. The commercial supporter may
       never pay honorarium directly to a speaker.


                                                                                                                 Rev. 12/ 17/09
       Any commercial support for this event must be acknowledged to the audience. You will need to provide a copy
       of the acknowledgment to the Office of CME, and a signed Letter of Agreement from the Commercial
       Supporter.

       You must submit a final budget documenting receipt and disbursement of commercial support if
       educational grant(s) are received.


10. CREDIT HOURS
    Please attach a copy of your program and indicate starting time and ending time for presentation(s).
    Number of CME Hours requested:


11. FACULTY
    Please attach a list of faculty for each section of your program, including name, title and organization.
    Attach curriculum vitae for each non-UNM School of Medicine instructor/presenter.


12. EDUCATION PLANNING:

       The faculty course director must complete and sign the Education Planning Form which is on the last page of
       this application.


13. ATTENDANCE
    The program organizer is responsible for recording attendance and the number of hours the participants
    attended. A typewritten list of attendees and their hours must be submitted to the Office of CME no later
    than 30 days after the conference.
    The certificates will be sent to you after the conference for you to distribute to participants.


14. SPONOSRSHIP STATEMENT
    The UNM Office of Continuing Medical Education must be listed as a sponsoring organization, and the
    UNM logo included.




15. ACCREDITATION STATEMENT
    Accreditation must be approved before you mail your brochure. You may not state that AMA
    Category 1 credit has been applied for.

   The following accreditation statement must appear on the promotional brochure:

   This activity has been planned and implemented in accordance with the Essential Areas and Policies of the
   Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the
   University of New Mexico Office of Continuing Medical Education and _____________________ (name of
   your organization). The University of New Mexico Office of Continuing Medical Education is accredited
   by the ACCME to provide continuing medical education for physicians.
                                                                                                          Rev. 12/ 17/09
  The Office of Continuing Medical Education designates this educational activity for a maximum of (number
  of credits) AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the
  extent of their participation in the activity.
  **When your application has been approved, the Office of CME will give you the number of credit
  hours to fill in he re.


16. BROCHURE REVIEW

  The Office of CME must approve the confe rence brochure before it is distributed. The following items
  must be included in your brochure:
  1. Conference Objectives
  2. UNM Office of CME listed as a sponsoring organization, with UNM Logo
  3. Accreditation Statement
  4. Detailed program agenda
  5. Faculty



  ___________________________________________________                    _________________________
  Signature of Program Chair                                             Date


  The Joint Sponsorship accreditation fee of $6,000 is due with the application.

  Please submit the Application and $6,000 application fee at least 30 days prior to your brochure mail date
                                            UNM Office of CME
                                 1 University of New Mexico – MSC09 5370
                                        Albuquerque, NM 87131-0001
                                  Phone: 505-272-3942      Fax 505-272-8604




                                                                                                   Rev. 12/ 17/09
EDUCATION PLANNING FORM – To be completed and signed by the faculty activity director

ACTIVITY:


1. What is the planning process for your CME activity?

       Yearly or periodic planning meetings
       Who attended?
       Please attach minutes/notes from the meeting(s) or summarize the meeting here
       If your department does not have an annual planning meeting, what is your process for identifying needs and
        choosing speakers and topics?

2. What sources did you use to identify educational needs?

       Evaluations from previous year
       Request from learner(s)
       Self-assessment tests
       Patient care audit/QA reports
       Mortality/morbidity statistics
       Faculty perception
       Survey of target audience

Please attach a summary of the survey results

        Other (Please List)



3. What are the desired results of the activity?
   _____ Increased MD learning?
   _____ Change in physician practice?
   _____ Change in patient outcome?


4. Based on the desired results of the activity, what are the objectives of the activity?




                                                                                                            Rev. 12/ 17/09
Please check all that apply:

Patient care
Medical knowledge                                X


Practice-based Learning & Improvement

Interpersonal & Communication Skills

Professionalism

Systems based practice

Provide patient-centered care

Work in Interdisciplinary Teams

Employ evidence-based practice

Apply Quality Improvement

Utilize Informatics




5. What are the quality gaps to be addressed? (For example, for patient care the quality gap is “the difference
   between present treatment success rates and those thought to be achievable using best practice guidelines. The quality
   gap may include but also can go beyond patient care to include systems’ base practice, informatics, leadership and
   administration.)




6. What is the professional practice gap? (The difference between actual and ideal performance and/or patient
   outcomes.)




7. The identified gap is in physician:
   _____ knowledge
   _____ skills
   _____ attitude
   _____ performance




                                                                                                            Rev. 12/ 17/09
8. What are the potential or real barriers facing these physicians if this need (Gap) is to be addressed?

       Examples:
       Patient-related
           * Patient adherence (medications, life style changes)
           * Cognition and memory
           * Side effects of medication
       Environment-related
           * Short time encounter with patients
           * Lack of tracking system to follow up with patients
           * Cost of care or lack of health insurance
           * Lack of multidisciplinary cooperation
       Provider-related
           * Adequate identification of patients w. _________________
           * Variation in physician decision (when to schedule tests, lab work)


9. Are there other organizations working on this issue? (Ex. DOH, NMMRA)




10. In what ways could we include these internal or external groups in our CME activity to help us address or
    remove the barriers identified?




11. What is the link to Q.I. or P.I.? How will this be incorporated in the series?




12. How will we formally measure outcomes from this activity?
       _____Audience Response
       _____Surveys
       _____Post Test
       _____NMMRA Quality Data


13. Are there non-educational strategies that are curre ntly being used that address this issue? If no, what
    kinds of non-educational strategies could be used to address this issue? (Examples: sending reminders
   about techniques or information discussed at a CME activity; patient surverys, a physician “report card” or peer
   feedback.)

       ___ Patient education cards
       ___ Reminders
       ___ Other ____________


                                                                                                            Rev. 12/ 17/09
_______________________________   __________________________   ___________
Course Director (please print)    Signature                    Date




                                                                        Rev. 12/ 17/09
                               CME ACCREDITATION CHECK LIST

Application for CME credit must include:

    1. Fully completed typed application form.

    2. Program agenda with time schedule, including breaks.

    3. List of all faculty for the program, including their title and organization. CV’s for all non-UNM faculty.

    4. Disclosures statements for all program planners and presenters.

    5. Evaluation form

    6. Application Fee

The Office of CME will review the program and send notification when it is approved for CME credit. The final program
brochure must be approved by the Office of CME prior to mailing.


No later than 1 week prior to the conference

    1. Disclosure summary of presenters’ and planners’ the disclosure information, financial relationships.

   2. Written Acknowledgment of Commercial Support to give to participants and signed Letter(s) of Agreement with
commercial supporters, (if applicable)

These must be submitted before the CME certificate will be issued.



No later than 30 days post conference, please submit:

   1. Typed list of the program attendees. Include address and last 4 numbers in their social security number, if available.
Each attendee must indicate how many hours they participated in the program.
   2. Summary of the Program Evaluations.
   3. Verification of Full Disc losure Checklist .
   4. Final budget documenting receipt and disbursement of commercial support if educational grant(s) are received.

All required paperwork must be submitted before the CME certificate will be issued.


Please call the Office of CME at 272-3942 if you have any questions or need assistance completing the application form.




                                                                                                              Rev. 12/ 17/09
     University of New Mexico Office Continuing Medical Education
                          Policy and Procedures
SUBJECT: Conflict of Interest Policy for Program Planners, Speakers and Authors
of Continuing Medical Education (CME) Activities


The mission of the University of New Mexico, Office of Continuing Medical Education is to improve
and enhance human health through education, research and patient care. It is committed to
providing continuing medical education (CME) to practicing physicians so that they maintain and
continuously improve their knowledge, skills, and attitudes throughout their professional lives.
University of New Mexico, Office of Continuing Medical Education requires that all individuals
participating in the planning and implementation of an educational activity must agree in writing to
adhere to the following principles:

     The content of CME activities and related materials provide balance, independence,
      objectivity, and scientific rigor.
     Planning must be free of the influence or control of a commercial entity, and promote
      improvements or quality in healthcare.
     All recommendations in CME activities involving clinical medicine must be based on evidence
      accepted within the medical profession.
     All scientific research used to support patient care recommendations must conform to
      generally accepted standards of experimental design, data collection, and analysis.
     The source and type of evidence will be made clear to participants.


   The University of New Mexico School of Medicine Office of CME discloses in writing all
    relationships by individuals involved in the development or presentation of the content.

   Based on disclosure information, the U niversity of New Mexico School of Medici ne Office of CME
    may disqualify any individual from planning an implementation if a conflict of interest that may
    contribute to commercial bias is determined to exist.

   All programs certified by the University of New Mexico School of Medicine Office of CME will be
    subject to monitoring for compliance with this policy and for peer-review of potential commercial
    bias.




                                                                                           Rev. 12/ 17/09
Disclosure of Relationships to Participants

All individuals who are in a position to control the content of an educational activity are required to
disclose all relevant relationships in any amount occurring within the past 12 months related both to
content and to commercials supporters of the activity including:
 The name of the individual
 The name of the commercial interests
 The nature of the relationship the individual has with each commercial interest(s)
        o Any individual who does not disclose relevant financial relationships will be disqualified
           from participating in planning and implementation of cme accredited educational
           activities.
        o All relationships must be disclosed in text format (print, slide, online) to participants prior
           to the presentation of the content of the activity; if no relationship exits, this must be
           disclosed in the same manner.
        o The source of all support from commercial interest, both monetary and in-kind support,
           must be disclosed to learners in a text format (print, slide, online) to participants prior to
           the presentation of the activity.




                                                                                              Rev. 12/ 17/09
Disclosure Statement
                                                                            Office of Continuing Medical Education
Activity title:____________________________________________________________________


By signing this document, I agree to the following elements as expected of individuals involved in
the planning and implementation of educational activities certified by the University of New Mexico
School of Medicine Office of CME. Please check each statement to indicate your agreement. I
agree to:

       Teach to the competencies identified by objectives

       Deliver balanced and objective evidence-based content

       Present the source and type or level of evidence (ie animal study, RCT, meta-analysis, etc) to the
       learners in my presentation

       Disclose any relationship related to (1) the activity’s content and/or (2) the activity’s supporter/s.
       Supporter/s of this activity include:

       _________________________________              _____________________________

       Supporters not known.

Please check one of the boxes below:

       I or members of my family do not have a financial arrangement related to (1) the content
        of this activity or (2) the supporters
                                      OR
       I or members of my family do have a financial arrangement related to (1) the content of
        this activity or (2) the supporters, as identified below

Type(s) of affiliations/financial interest(s) and name of corporation(s)

       Grants/research support: __________________________________________

       Consultant: _____________________________________________________

       Stock shareholder (directly purchased): _______________________________

       Honorarium: ____________________________________________________

       Other financial or material support: ___________________________________



Signature                                     Print name & degree                                    Date


                                                                                                         Rev. 12/ 17/09
 EVALUATION FORM
                                                        Office of Continuing Medical Education

ACTIVITY:____________________________________________ DATE: __________________

PRESENTATION TITLE: ________________________________________________________

          PRESENTE R: ______________________ ___________________________________________

PROGRAM OBJECTIVE(S): _____________________________________________________
YOUR TITLE:   PHYSICIA N     PA     NP     CNM       OTHER__________________________


This program:                            STRONGLY DISAGREE                STRONGLY AGREE
Met the stated objectives:                              1       2         3        4        5

Delivered balanced and objective,                       1        2         3       4        5
evidence-based content?

Presented the source and type or level of evidence
(ie animal study, RCT, meta-analysis, etc)              1        2         3       4        5

Did you feel this presentation conveyed any commercial bias?            Yes_____       No_____

COMMENTS:

Please rate the effectiveness of the       NOT EFFECTIVE                VERY EFFECTIVE
presenter(s)                                     1     2            3       4      5

COMMENTS:

Information from this activity will be     STRONGLY DISAGREE            STRONGLY AGREE
incorporated into my medical practice:          1      2     3             4      5

Provided practical suggestions I can apply       1          2       3          4       5
in my practice…

Changes in my practice that I am going to make…..
1. _________________________________________
2. _________________________________________
3. _________________________________________

If no changes, what are the barriers…
1. _________________________________________
2. _________________________________________
3. _________________________________________

Please list topics of interest to you for future activities:
___________________________________________________________________________
                                                                                                 Rev. 12/ 17/09
                                                          LETTER OF AGREEMENT

                                      Regarding Terms, Conditions and Purposes of an Educational Grant
                                             for a University of New Mexico School of Medicine
                                          Office o f Continuing Medical Education Program (OCM E)

                                                      (Form must be typed or printed legibly)

between UNM Office of Continuing Medical Education and
                                                                                  (co mpany)

Title of CM E Activ ity

Location                                                                                   Date(s)

Co mmercial Supporter (Co mpany name/Branch)

Address

City, State, Zip

Telephone                            Fax                               Contact Person

The above company wishes to provide support for the named continuing medical education activity by means of (indicate wh ich
option):

1.         Unrestricted educational grant for support of the CME act ivity in the amount of $

2.         Restricted grant to sponsor:
           A. Speaker(s) 1)                                            2)

           To include: All expenses and honorariu m               Travel/Meals only             Honorariu m only

           Honorariu m amount (to be determined by Course Director) $

           B. Support for catering functions (specify)

                       In the amount of $

           C.          Other (e.g., equip ment loan, brochure d istribution, etc.)




                                                                   CONDITIONS

1.         S tatement of Purpose: program is for scientific and educational purposes only and will not promote the company's products, directly or
           indirectly.

2.         Control of Content & Selection of Presenters & Moderators: OCM E is responsible for control of content and selection of presenters
           and moderators. The Company agrees not to direct the content of the program. The Company or its agents, will respond only t o OCM E-
           initiated requests for suggestions of presenters or sources of possible presenters. The Company will suggest more than one name (if
           possible); will provide speaker qualifications; will disclose financial or other relationships between Company and speaker, and will provide
           this information in writing. OCM E will record role of Company, or its agents, in suggesting presenter(s); will seek suggestions from other
           sources, and will make selection of presenter(s) based on balance and independence.


                                                                                                                                       Rev. 12/ 17/09
3.          Disclosure of Financial Relationships: OCM E will ensure meaningful disclosure to the audience, at the time of the program, of (a)
            Company funding, and (b) any significant relationship between the OCM E and the Company (e.g., grant recipient) or between individual
            speakers or moderators and the Company.

4.          Invol vement in Content: there will be no "scripting", emphasis, or direction of content by the Company or its agents.

5.          Ancillary Promotional Activities: no promotional activities will be permitted in the same room or obligate path as the educational
            activity. No product advertisements will be permitted in the program room.

6.          Objectivity & Balance: OCM E will make every effort to ensure that data regarding the company's products (or competing products) are
            objectively selected and presented, with favorable and unfavorable information and balanced discussion of prevailing information on the
            product(s) and/or alternative treatments.

7.          Limitations of Data: OCM E will ensure, to the extent possible, meaningful disclosure of limitations on data, e.g., ongoing research,
            interim analyses, preliminary data, or unsupported opinion.

8.          Discussion of Unapproved Uses: OCM E will require that presenters disclose when a product is not approved in the United States for the
            use under discussion.

9.          Opportunities for Debate: OCM E will ensure meaningful opportunities for questioning or scientific debate.

10.         Independence of OCME in the use of Contributed Funds:
                      a. funds should be in the form of an educational grant made payable to UNM OCM E.
                      b. all other support associated with this CM E activity (e.g., distributing brochures, preparing slides, etc.) must be given with
                             the full knowledge and approval of OCM E.
                      c. no other funds from the commercial company will be paid to the program direct or, faculty, or others involved with the
                             CM E activity (additional honoraria, extra social events, etc.).

The Commercial Supporter agrees to abide by all requirements of the ACCM E Standards for Commercial Support of Continuing Medical Education
(appended).

The Accredited Sponsor agrees to: 1) abide by the ACCM E Standards for Commercial Support of Continuing Medical Education; 2) acknow ledge
educational support from the commercial company in program brochures, syllabi, and other program materials, and 3) upon request, furnish the
commercial supporter a report concerning the expenditure of the funds provided.



                                                                       AGREED

Commercial Company Representative

Signature                                                     Date

CM E Department

Signature                                                     Date




                                                                                                                                        Rev. 12/ 17/09
                                                        SAMPLE
                                North American Neuro-Ophthamology Society Meeting
                                                March 26-30, 2000

                                               SPONSORED BY:
                                 The North American Neuro-Ophthalmology Society
                                                        &
                        The University of New Mexico Office of Continuing Medical Education




Objectives:             At the conclusion of the meeting participants should be able to:

                           Understand the issues involved in the treatment of idiopathic intracranial hypertension and
                            thyroid eye disease.
                           Understand the latest thinking and consensus regarding pharmacologic treatment of stroke,
                            migraine, nystagmus, optic neuropathy and dystonias.

Acknowledgment:         This event is supported by an unrestricted educational grant from Parke-Davis.

Disclosure:             The speakers and planners listed below disclose that they have no financial interest or other
                        relationships with the manufacturer(s) of commercial products related to the content of this
                        presentation.

                        Michael Wall, MD
                        Valerie Purvin MD

                        John Shriver, MD discloses that he is on the Speaker’s Bureau for Pfizer, and has a research grant
                        from Wyeth Ayerst.

Accreditation:
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation
Council for Continuing Medical Education (ACCME) through the joint sponsorship of the University of New Mexico
Office of Continuing Medical Education and the North American Neuro-Ophthalmology Society. The University of New
Mexico Office of Continuing Medical Education is accredited by the ACCME to provide continuing medical education
for physician.

The Office of Continuing Medical Education designates this continuing medical education activity for a maximum of 26.5
AMA PRA Category 1 Credit(s)tm . Physicians should claim only credit commensurate with the extent of their participation
in the activity.




                                                                                                              Rev. 12/ 17/09

				
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