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									5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                         Visit our Web site at www.nmmra.org
         Continuing Medical Education (CME)
                      Regularly Scheduled Series (RSS)
                                                                    Application Packet
                                                                                                  July 2010

Continuing Medical Education (CME) Application
Thank you for your interest in submitting a Continuing Medical Education (CME) program application
to the New Mexico Medical Review Association (NMMRA) for consideration. CME approval requires
the program to be directed at physician education. CME consists of educational activities that serve to
maintain, develop or increase the knowledge, skills and professional performance of the medical
profession. The content of CME must be evidence-based and conform to generally accepted standards
within the basic medical sciences. NMMRA is accredited by the New Mexico Medical Society (NMMS),
which is recognized by the Accreditation Council for Continuing Medical Education (ACCME). ACCME
defines “regularly scheduled series (RSS),” as weekly or monthly CME activities that are primarily
planned by and presented to the provider’s professional staff.
This packet of information contains instructions, forms to be completed and sent to NMMRA for
approval before the RSS CME program is conducted for credit, template materials that can be
customized for use during the program, and processes that should be followed to ensure that your
program meets recognized standards of CME. For fee information, see Form I, Agreement for Joint
Sponsorship of a CME Event Series.
Please review the entire contents of this packet before completing the forms. You may submit
completed forms in hard copy by faxing or mailing them, attention: CME Committee, 5801 Osuna NE,
Suite 200, Albuquerque, NM 87109, or fax to (505) 998-9899, or attach completed application to an e-
mail and send to cmecoordinator@nmmra.org. If you have questions about the completion of these
forms, contact Courtney Overton, NMMRA CME Coordinator, at (505) 314-9013 or by e-mail at
coverton@nmmra.org. Download this document at www.nmmra.org/cme/index.php.

Material contained in this packet:
Processes to be followed                                                                                                     Page
Responsibilities of the CME Series Planner and CME Coordinator ............................................ 3
CME Event Development Timeline .............................................................................................. 4
Forms
CME Application (Form A)* ........................................................................................................ 6
Event Agenda Information (Form B)* .......................................................................................... 8
Needs Assessment (Form C)* ....................................................................................................... 9
Educational Objectives (Form D)* ............................................................................................. 10
Biographical Data (Form E)** ..................................................................................................... 11

                          CME Regularly Scheduled Series Application                                                   Page | 2
  5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                           Visit our Web site at www.nmmra.org                             Revised July 2010
Faculty Disclosure Declaration (Form F)**................................................................................ 12
CME Event Attendance Sheet (Form G)*** ................................................................................15
CME Activity Evaluation (Form H)*** ........................................................................................ 17
Agreement for Joint Sponsorship of a CME Event Series (Form I) ........................................... 18
Post-event Evaluation Report (Form J)(optional) ..................................................................... 20
NMMRA Written Agreement for Commercial Support (if applicable) (Form K)....................... 17
*Forms that must be completed and approved by NMMRA‟s CME Committee prior to the CME event.
**Only one copy each of these two forms is included in this packet; additional copies may be required.
***An event attendance sheet and activity evaluation forms must be prepared and approved by NMMRA‟s
  CME Committee prior to the CME event (attendees will complete these forms at the time of the
  activity/event).Individual certificates and CME credit will not be awarded until Forms G and H are provided
  to NMMRA after the event.



Responsibilities of the CME Series Planner and CME Coordinator

                                                                                            Sends or directs the
                          CME Series Planner                                                 sending of invitations for
     NMMRA employee or joint sponsor requesting CME                                          each CME event in the
                                                                                             series, adhering to
The CME Series Planner serves as project manager for the particular                          ACCME standards (see
CME event series being planned.                                                              Joint Sponsorship
This person:                                                                                 Information page, #2)
 Organizes the event series or directs the organization of the event                       Receives or directs the
   series logistically                                                                       receipt of RSVPs for the
 Organizes and submits CME application materials to the CME                                 CME event series
   Coordinator                                                                              Completes or directs the
   o Form A: CME application                                                                 completion of sign-in
   o Form B: Event Series Planner may have a                                                 sheets based on RSVP
       branded/customized printed agenda for each event in the                               information
       series                                                                               Facilitates completion of
   o Forms C, D and E: Needs assessment, objectives and                                      event sign-in sheets and
       biographical data                                                                     event evaluations the day
   o Form F: To be completed and signed by each speaker, and                                 of each CME event in the
       faxed or mailed to NMMRA to obtain CME approval                                       series
   o Form G: May be branded by the Series Planner; if the CME                               Turns in completed sign-
       event is jointly sponsored with NMMRA, please keep                                    in sheets, evaluations, and
       NMMRA’s logo on this form                                                             Disclosure of Relevant
   o Form H: The Series Planner may brand the evaluation form                                Financial Relationships
       and additional questions may be added; however, current                               Attestation Form to CME
       evaluation questions are the minimum required to satisfy                              Coordinator after each
       ACCME; if the event series is jointly sponsored with NMMRA,                           event (Note: certificates
       please keep NMMRA’s logo on the form                                                  cannot be issued and CME
   o Form J: Completion of this form is optional; although, your                             credit awarded to
       assistance in completing the form will help us make                                   participants without
       improvement to the CME approval process for future event                              completion and
       series.                                                                               submission of the event
                                                                                             attendance sheet and
                                                                                             activity evaluation forms)


                         CME Regularly Scheduled Series Application                                               Page | 3
  5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                           Visit our Web site at www.nmmra.org                             Revised July 2010
     See Form I, page 14, for Joint Sponsorship Event Series
      Application fee schedule and Form K, page 17, NMMRA Written
      Agreement for Commercial Support (if applicable)

                             CME Coordinator
                              NMMRA employee
                        in charge of CME program
The CME Coordinator ensures the integrity of NMMRA’s CME
Program by supervising CME requests, committee meetings,
approvals, evaluations and certificates.
This person:
 Maintains, sends and receives completed CME application and
   associated documents from Series Planner for submission to
   CME Committee
 Organizes CME Committee meeting and sends calendar
   appointments
 Notifies Series Planner of CME Committee ruling
 Receives completed sign-in sheets, event evaluations, and
   Disclosure of Relevant Financial Relationships Attestation Form
 Compiles evaluation summaries
 Retains event documentation for six years
 Prepares and distributes CME certificates to event participants
   after each event




                          CME Regularly Scheduled Series Application                                            Page | 4
    5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                             Visit our Web site at www.nmmra.org                             Revised July 2010
CME Event Development Timeline
    A need for CME activity is identified through data analysis or personal request. Sponsor of CME forms a
                                 team to prepare and present the CME activity.


  Contact NMMRA to                                Eight Weeks Prior to the First Event of the Series
   request fast-track                   Event Planner (sponsor) of the CME activity completes CME application
        review                          along with the disclosure forms/biographical information and submits it to
                                                                   the CME Coordinator

                                    CME Coordinator schedules the application                       Resubmit or
                                        review with the CME Committee                                withdraw
                                                                                                    application




                                              Six Weeks Prior to the First
                                                  Event of the Series
                                              CME Committee reviews and
                                            approves/disapproves the request;
                                            CME Coordinator notifies sponsor
                                                   of approved credits




                                   Four Weeks Prior to Each Event of the Series
                                                       Event sponsor:
                       • Coordinates invitation letter/brochure and mails invitations (to include the
                               appropriate financial support and advertising statements)
                                     • Receives RSVPs/compiles attendance sheet
                                                • Prepares evaluation form


                                                           Day of             Sponsor has participants
                                                           Each              sign attendance sheet and
                                                           Event                complete evaluations


                                       One Week After Each Event of the Series
                         Sponsor provides CME Coordinator with completed attendance sheet
                         with participants’ addresses, evaluation forms, Disclosure of Relevant
                             Financial Relationships Attestation Form and post-event report

                                              Two Weeks Post Event
                         CME Coordinator prepares CME certificates and evaluation summaries


                        CME Coordinator maintains required files of activity materials for six years




                       CME Regularly Scheduled Series Application                                            Page | 5
 5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                          Visit our Web site at www.nmmra.org                             Revised July 2010
                                                                                                                  Form
                                                                                                                   A
CME Application
Submitted by:                                                   Date of Submission:
CME Topic:
Target Audience:
Expected Attendance at Each Event:
Is this a recurring medical staff                               or   Recurring stand-alone
meeting?                                                             presentations?
Effective Date:                                     Termination Date:
How often will these courses be
held?
(Bi-annually, Quarterly, Monthly, Bi-Monthly, Bi-Weekly, Weekly or Other (specify number of
occurrences)
Date/Time of Each                  /                        /                        /                        /
Event in the                       /                        /                        /                        /
Series:                            /                        /                        /                        /
Locations
:

            If more than one location, please include all locations for this reoccurring course.
            Provide addition sheets if necessary.
Length of
Presentation:
One CME hour equals 60 minutes of activity, and each 15 minutes equals .25 credits (see Form
B).
Type of
Presentation:
Lecture, workshop, symposium, etc.
Faculty/Speaker(s)
:

Required forms:                                                                                     CME Committee Only
Event Agenda – Form B                                                                               Yes           No
Needs Assessment – Form C                                                                           Yes           No
Educational Objectives – Form D                                                                     Yes           No
Biographical Data (curriculum vitae for each speaker) – Form E                                      Yes           No
Faculty Disclosure Declaration (for each speaker) – Form F                                          Yes           No
CME Event Attendance Sheet (submit following each event) – Form G                                   Yes           No
CME Activity Evaluation – Form H                                                                    Yes           No
Agreement for Joint Sponsorship (if an associate organization) – Form I                             Yes           No
Optional forms:
Post-Event Evaluation Report (submit following the series) – Form J                                 Yes           No
NMMRA Written Agreement for Commercial Support – Form K                                             Yes           No

                        CME Regularly Scheduled Series Application                                            Page | 6
  5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                           Visit our Web site at www.nmmra.org                             Revised July 2010
CME Committee Only:
Comments: ____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
CME Committee Approval Date: _____________________________________________________
CME Committee Chairman Signature: __________________________________________________




                       CME Regularly Scheduled Series Application                                            Page | 7
 5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                          Visit our Web site at www.nmmra.org                             Revised July 2010
                                                                                                               Form
                                                                                                                  B
Event Agenda Information
Note: Series Planner may have a branded/customized, printed agenda for each event.
Title of Event:
Date:
Time:
Location:

                                              ----- Agenda Topics -----
 Topic (include registration, breaks and questions)                                 Presenter             Time




An Event Agenda must be submitted listing each topic covered and indicating presenter and the time
frame for each topic. The time allowed for registration, breaks, non-working lunch, and
questions/answers must be shown and accounted for on this form. Disclose the financial interests
and affiliations of each speaker to the audience (Form F). (A Disclosure of Relevant Financial
Relationships Attestation Form will be provided by the CME Coordinator to the Series Planner when
the series of events has been approved.)



                       CME Regularly Scheduled Series Application                                            Page | 8
 5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                          Visit our Web site at www.nmmra.org                             Revised July 2010
                                                                                                                Form
                                                                                                                   C
Needs Assessment
Identified educational needs:




Include sources used to determine how these needs were identified:




The Series Planner must use a planning process(es) that links identified educational needs with a
desired result in its provision of all CME activities. The Series Planner must use needs assessment
data to plan CME activities. Identified needs from multiple sources may be used to initiate and
support the planning process.




                        CME Regularly Scheduled Series Application                                            Page | 9
  5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                           Visit our Web site at www.nmmra.org                             Revised July 2010
                                                                                                               Form
                                                                                                                  D
Educational Objectives
What can the attendee expect to learn from this event?




                       CME Regularly Scheduled Series Application                                            Page | 10
 5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                          Visit our Web site at www.nmmra.org                             Revised July 2010
                                                                                                                Form
                                                                                                                   E
Biographical Data
(Complete one form for each presenter/speaker)

Name and
Degrees:
Present Position
and Description:


Employer:
Address:
E-mail:
Telephone:


 Education (include basic preparation through highest degree held)
 Degree                        Year Awarded         Institution (Name, City, State)           Major Area of Study




Briefly describe your professional experience or areas of expertise (including publications) which
contribute to your particular involvement in this continuing medical education (CME) activity:




                        CME Regularly Scheduled Series Application                                            Page | 11
  5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                           Visit our Web site at www.nmmra.org                             Revised July 2010
                                                                                                                Form
                                                                                                                   F
Faculty Disclosure Declaration
To be completed and signed by each speaker. Fax or mail this form to NMMRA to obtain CME
approval.
Today’s date:
Faculty
member/author/teacher:
CME activity title:
Date of activity:
Location:
City:

The New Mexico Medical Review Association (NMMRA) is accredited by the New Mexico Medical
Society (NMMS), which is recognized by the Accreditation Council for Continuing Medical Education
(ACCME). As such, we have made the choice to meet the ACCME’s expectations for our practice of
continuing medical education (CME). Our accreditation is important to us. We look forward to
working together to provide CME at the highest standard. Please disclose all relevant financial
relationships with any commercial interest (see below for definitions). Should it be determined that a
conflict of interest exists as a result of a financial relationship you may have, this will need to be
resolved prior to the activity. If you refuse to disclose relevant financial relationships, you will be
disqualified from being a part of the planning and implementation of this CME activity.
First, list the names of proprietary entities producing health care goods or services, with the
exemption of non-profit or government organizations and non-health care related companies with
which you or your spouse/partner have, or have had, a relevant financial relationship within the past
12 months. For this purpose we consider the relevant financial relationships of your spouse or partner
that you are aware of to be yours.
Second, describe what you or your spouse/partner received (example: salary, honorarium, etc.).
NMMRA does NOT want to know how much you received.
Third, describe your role.

Please check the appropriate box, supply any commercial interest information in the table on the
following page, sign, date and mail or fax to the CME Coordinator at NMMRA. To assist you, an
example is provided in the first row. Also, below the table are examples of what might have been
received or roles.
       I do not have any relevant financial relationships with any commercial
       interests.
       I have the following relevant financial relationships with commercial
       interests. (Complete table on the next page)




                        CME Regularly Scheduled Series Application                                            Page | 12
  5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                           Visit our Web site at www.nmmra.org                             Revised July 2010
                                                         Nature of Relevant Financial Relationship
          Commercial Interest                                   (Include all those that apply)
                                                      What I Received                      My Role
Example: Company „X‟                                    Honorarium                                Speaker




                           Signature
                                                                  Date

What was received: Salary, royalty,                        My role(s): Employment, management position,
intellectual property rights, consulting fee,              independent contractor (including contracted
honoraria, ownership interest (e.g., stocks,               research), consulting, speaking and teaching,
stock options or other ownership interest,                 membership on advisory committees or review
excluding diversified mutual funds), or other              panels, board membership, and other activities.
financial benefit.



                                                Glossary of Terms
Commercial Interest
  The ACCME defines a “commercial interest” as any proprietary entity producing health care goods
  or services, with the exemption of non-profit or government organizations and non-health-care-
  related companies.
Financial Relationships
   Financial relationships are those relationships in which the individual benefits by receiving a
   salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g.,
   stocks, stock options or other ownership interest, excluding diversified mutual funds), or other
   financial benefit. Financial benefits are usually associated with roles such as employment,
   management position, independent contractor (including contracted research), consulting,
   speaking and teaching, membership on advisory committees or review panels, board membership,
   and other activities from which remuneration is received, or expected. ACCME considers
   relationships of the person involved in the CME activity to include financial relationships of a
   spouse or partner.
Relevant Financial Relationships
   ACCME focuses on financial relationships with commercial interests in the 12-month period
   preceding the time that the individual is being asked to assume a role controlling content of the
   CME activity. ACCME has not set a minimal dollar amount for relationships to be significant.
   Inherent in any amount is the incentive to maintain or increase the value of the relationship. The
   ACCME defines “relevant financial relationships” as financial relationships in any amount
   occurring within the past 12 months that create a conflict of interest.
Conflict of Interest



                        CME Regularly Scheduled Series Application                                            Page | 13
  5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                           Visit our Web site at www.nmmra.org                             Revised July 2010
  Circumstances create a conflict of interest when an individual has an opportunity to affect CME
  content about products or services of a commercial interest with which he/she has a financial
  relationship.




                      CME Regularly Scheduled Series Application                                            Page | 14
5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                         Visit our Web site at www.nmmra.org                             Revised July 2010
 Insert logo
                                                                                                                            Form
                                                                                                                              G
CME Event Attendance Sheet (complete for each event in the series)
Title of Event:
Date:
Time:
Location:
Please print legibly and include complete mailing address if requesting a Continuing Medical
Education (CME) Certificate
          Print Full Name                                                                                    Please check one
Initial




                                                                             Zip    E-mail Address and
          and                  Mailing Address           City        State                                                 Non-
                                                                             Code   Phone Number             MD    DO
          Specialty                                                                                                         MD




                      New Mexico Medical Review Association (CME Regularly Scheduled Series)        Page | 15 (revised July 2010)
          Print Full Name                                                                                    Please check one
Initial


                                                                             Zip    E-mail Address and
          and                  Mailing Address           City        State                                                 Non-
                                                                             Code   Phone Number             MD    DO
          Specialty                                                                                                         MD




                      New Mexico Medical Review Association (CME Regularly Scheduled Series)        Page | 16 (revised July 2010)
 Insert logo                                                                                                   Form
                                                                                                                 H

CME Activity Evaluation
Title of Event:
Date:
Time:
Location:
Please check the appropriate column when using the following codes to answer the items
below.
1=Strongly Disagree                    3=Undecided                    4=Agree
2=Disagree                                                            5=Strongly Agree
                                                                        1    2 3 4                                    5
Topic
The presenter(s) communicated effectively.
The presenter(s) allowed enough time for questions and answers.
The presenter(s) and presentation(s) illustrated independence,
objectivity, and balance.
The content was appropriate for my level of expertise.
The presentation was free of commercial bias.
Program
The program description, target audience, and educational objectives
were clearly stated at the beginning of the program.
The financial support for this event is clearly stated.
The program was well planned and implemented.
The program met stated objectives.
The program met my professional expectations and needs.
I expect to apply the information/skills learned from this program in
my professional practice.
The content was up to date.
The content was closely related to the objectives of my professional
practice.

(Optional) Participant’s name: ____________________ Phone: ________________

I would like to see the following topics in future presentations: _____________________
 ________________________________________________________________
 ________________________________________________________________
 ________________________________________________________________

Comments: ________________________________________________________
 ________________________________________________________________
 ________________________________________________________________
 ________________________________________________________________




                      CME Regularly Scheduled Series Application                                            Page | 17
 5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                       Visit our Web site at www.nmmra.org                                Revised July 2010
                                                                                                               Form I

Agreement for Joint Sponsorship of a CME Event Series Between
NMMRA and ___________________________________________
                    (Organization Name)
Series Sponsor shall:                                            NMMRA shall:
Submit CME application package, which                            Review the application.
includes:
                                                                 If the application is approved, NMMRA shall
1. Completed CME Application (Form A)
                                                                 perform the following pre-event activities:
2. Event Agenda (Form B)
                                                                 1. Invoice for fees
3. Needs Assessment (Form C)
                                                                 2. Provide template sign-in sheet
4. Educational Objectives (Form D)
                                                                 3. Provide template evaluation form
5. Biographical Data for each speaker (Form E)
                                                                 4. Provide Disclosure of Relevant Financial
6. Faculty Disclosure Declaration for each
                                                                      Relationships Attestation Form
    speaker (Form F) (send in by mail or fax)
7. CME Activity Evaluation (Form H)                              NMMRA shall perform post-event activities as
8. Joint Sponsorship Agreement (if associate                     follows:
    organization) (Form I)                                       1. Provide CME certificates to event attendees
9. Application fee as shown in the “NMMRA                        2. Analyze evaluations and provide feedback to
    shall” column of this page                                       your organization
If the event series is approved, Series Sponsor                  If the application is rejected, NMMRA shall:
shall perform these pre-event activities:                        1. Provide feedback to the Series Sponsor
1. Apply appropriate language (supplied by                            regarding the rejection
     NMMRA) to brochures and fliers                              NMMRA will perform these activities according
2. Disclose the financial interests and affiliations             to the following rate schedule:
     of each speaker to the audience (Form F)
                                                                 The sponsor should estimate the combined
Perform these activities during each event:                      number of attendees that are expected to attend
1. Provide and collect event attendance sheets
                                                                 the series during the year.
   (Form G)                                                                50 or less attendees: $600
2. Provide and collect approved evaluation                                  51-100 attendees: $750
   forms (Form H)                                                          101-200 attendees: $900
Perform post-event activities after each event:
1. Deliver sign-in sheets, completed event                       If at the end of the year the actual number of
   evaluations, and Disclosure of Relevant                       attendees exceeds the estimated number,
   Financial Relationships Attestation forms to                  NMMRA will invoice for the balance due.
   NMMRA for recording and statistical analysis
2. Provide post-series evaluation report (Form
   J)

For CME Series Sponsor:                                         For NMMRA:

Signature                                                       Signature

Printed Name and Title                                          Printed Name and Title

Date                                                            Date



                       CME Regularly Scheduled Series Application                                            Page | 18
  5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                        Visit our Web site at www.nmmra.org                                Revised July 2010
Joint Sponsorship Information
Through our CME accreditation, NMMRA can provide a unique service to our business
associates: CME credit for a series of identical events that they organize and implement.
Working with associate organizations to provide CME:
Because NMMRA is an accredited provider of CME units, our associates often seek us out to
provide CME for their events. We have a few guidelines regarding these relationships:
1. At times, in the interest of relationship building, senior management may approve an
   exchange of our CME application fee for the organization’s booth fee at the event, if
   appropriate. However, it is important to make a distinction between waiving the
   application fee and actually approving the CME units. The CME Committee must review
   the application on the merits of the program with the completion of all of the appropriate
   paperwork.

2. It is important that the proper language be used on promotional items and event materials
   to include slides and handouts.
   Prior to approval of the CME event, CME credit hours cannot be advertised.
   Following CME Committee approval of an event, the following statements shall appear on
   the final flyer/brochures:
       This activity has been planned and implemented in accordance with the
       Essential Areas and policies of the New Mexico Medical Society (NMMS)
       through the joint sponsorship of the New Mexico Medical Review Association
       (NMMRA) and (name of non-accredited provider). NMMRA is accredited by
       the NMMS to provide Continuing Medical Education for physicians.
       NMMRA designates this educational activity for a maximum of (X) AMA PRA
       Category 1 Credit(s)™. Physicians should only claim credit commensurate with the
       extent of their participation in the activity.
   Slides and reference materials shall not by their content or format, advance the specific
   proprietary interest of the commercial supporter.

3. Commercial support disclosure statement for brochures and agendas:
   This event is brought to you by (funding [and usually organizing] source). The speaker,
   (name of speaker), is sponsored by (name and short description of company).

   Commercial support must be acknowledged in material prior to the event; however,
   reference must not be made to specific products. The source of all support from
   commercial interests will be identified by completion of the NMMRA Written Agreement
   for Commercial Support (Form K) and will be disclosed to learners at the time of the
   event. When commercial support is “in-kind,” the nature of the support must be disclosed
   to learners.



                      CME Regularly Scheduled Series Application                                            Page | 19
 5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                       Visit our Web site at www.nmmra.org                                Revised July 2010
                                                                                                              Form J

Post-event Series Evaluation Report
Name:
E-mail:
Telephone:
Title of event:
Dates of events:


Was the granting of continuing medical education (CME) credits a worthwhile benefit to you and your
attendees?
      Yes
      No

Please comment on the CME process:


A. Note effective or innovative aspects:




B. Note difficult or problematic issues:




Other comments/notes:




                      CME Regularly Scheduled Series Application                                            Page | 20
 5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                       Visit our Web site at www.nmmra.org                                Revised July 2010
                                                                                                                         Form
                                                                                                                            K
NMMRA Written Agreement for Commercial Support
NMMRA is committed to presenting continuing medical education (CME) activities that promote
improvements or quality in health care and are independent of the control of commercial interests. As
part of this commitment, NMMRA has outlined in this written agreement the terms, conditions and
purposes of commercial support for its CME activities. Commercial Support is defined as financial or
in-kind contributions given by a commercial interesti, which is used to pay all or part of the costs of a
CME activity.

 Title of CME activity:

     Activity location:                                                 Activity frequency:

 Name of commercial interest:

 Amount of educational grant:
 (direct or in-kind)

 Grant will be used for the following:

 Speaker honoraria:              Speaker expenses                Meeting expenses               Other (list):
                                 (itemize):                      (itemize):




                                          Terms, Conditions, and Purposes
Independence
1.     This activity is for scientific and educational purposes only and will not promote any specific proprietary business
       interest of the Commercial Interest.
2.     The Accredited Provider is responsible for all decisions regarding the identification of educational needs, determination
       of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a
       position to control the content of the CME, selection of education methods, and the evaluation of the activity.

Appropriate Use of Commercial Support
3.     The Accredited Provider will make all decisions regarding the disposition and disbursement of the funds from the
       Commercial Interest.
4.     The Commercial Interest will not require the Accredited Provider to accept advice or services concerning teachers,
       authors, or participants or other education matters, including content, as conditions of receiving this grant.
5.     All commercial support associated with this activity will be given with the full knowledge and approval of the Accredited
       Provider. No other payments shall be given to the director of the activity, planning committee members, teachers or
       authors, joint sponsor, or any others involved with the supported activity.
6.     The Accredited Provider will upon request, furnish the Commercial Interest documentation detailing the receipt and
       expenditure of the commercial support.

Commercial Promotion
7.     Product-promotion material or product-specific advertisement of any type is prohibited in or during the CME activity.
       The juxtaposition of editorial and advertising material on the same products or subjects is not allowed. Live or enduring
       promotional activities must be kept separate from the CME activity. Promotional materials cannot be displayed or
       distributed in the education space immediately before, during or after a CME activity. Commercial Interests may not
       engage in sales or promotional activities while in the space or place of the CME activity.
8.     The Commercial Interest may not be the agent providing the CME activity to the learners.




                           CME Regularly Scheduled Series Application                                                  Page | 21
     5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                           Visit our Web site at www.nmmra.org                                Revised July 2010
Disclosure
9.     The Accredited Provider will ensure that the source of support from the Commercial Interest, either direct or “in-kind,” is
       disclosed to the participants, in program brochures, syllabi, and other program materials, and at the time of the activity.
       This disclosure will not include the use of a trade name or a product-group message. The acknowledgment of commercial
       support may state the name, mission, and clinical involvement of the company or institution and may include corporate
       logos and slogans, if they are not product promotional in nature.

The Commercial Supporter and NMMRA agree to abide by all requirements of the Accreditation
Council for Continuing Medical Education (ACCME) Standards for Commercial Support of
Continuing Medical Education (appended).


    Name of Accredited Provider:
     Tax ID Number:
     Contact Person:                                                                E-mail Address:
     Phone Number:                                                                  Fax Number:

    Educational Partner (if applicable):
     Contact Person:                                                                E-mail Address:
     Phone Number:                                                                  Fax Number:
     Tax ID Number:

    Name of Commercial Interest:
     Address:
     City, State, Zip:
     Contact Person:                                                                E-mail Address:
     Phone Number:                                                                  Fax Number:

                                Agreed by Authorized Representatives
    Commercial Interest                                               Accredited Provider

    Signature and Date                                                Signature and Date

    Printed Name                                                      Printed Name

    Title                                                             Title
                                                                      Educational Partner (if applicable)

                                                                      Signature and Date

                                                                      Printed Name

                                                                      Title


i
    The ACCME defines a Commercial Interest as any proprietary entity producing health care goods or services, with the
    exemption of non-profit or government organizations and non-health care related companies. The ACCME does not
    consider providers of clinical service directly to patients to be commercial interest.




                          CME Regularly Scheduled Series Application                                                Page | 22
     5801 Osuna Road NE, Suite 200  Albuquerque, New Mexico 87109-2587  (505) 998-9898  (800) 663-6351  (505) 998-9899 fax
                                           Visit our Web site at www.nmmra.org                                Revised July 2010

								
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