• Office of Continuing Physician Professional Development/CME: JOINT SPONSORSHIP APPLICATION

  • Organization Information

  • Leadership and Administration

  • Activity Medical Director:

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  • Activity Coordinator:

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  • Person completing this application if different than above:

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  • Activity Planning Committee:

    ACCME 2006 Updated Criteria require that anyone in a position to influence or control the content of an educational activity must disclose all relevant financial relationships with any commercial interest(s) in order to address potential bias in the educational content.  The accreditation process will not advance until all members of the planning committee have submitted a completed electronic disclosure form.

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    • Additional Activity Planners: (click on arrow to add more planners)  
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    • Activity Description

    • Needs Assessment:  Identified Gaps in Knowledge, Competence, Performance or Patient Outcomes

      A knowledge/practice gap is the different between current and ideal performance and is a key tool for planning the activity.  These gaps are measured in terms of:

      Knowledge

      Competence

      Performance

      Additionally, this information serves as the foundation for all aspects of activity design, including preparation of learning objectives, choice of educational format(s), and the selection of appropriate outcomes assessment tools.

    • Indicate findings of needs assessment:

    • Indicate the sources used to identify learner gaps/need and provide documentation of each.  These must illustrate gaps between current and best practice.

    • **Please upload documentation supporting needs assessment.

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    • Professional Practice Gap and Learner Objectives

      Describe the professional practice gap (the difference between ideal and current practice) that informs each learner objective specific to the target audience.

    • Professional Practice Gap and Learner Objective #1

    • Desired outcome #1

      Indicate a measurable change that is anticipated as a result of participation in the activity by completing the appropriate sentence below:

    • Professional Practice Gap and Learner Objective #2

    • Desired outcome #2

      Indicate a measurable change that is anticipated as a result of participation in the activity by completing the appropriate sentence below:

    • Professional Practice Gap and Learner Objective #3

    • Desired Outcome #3

      Indicate a measurable change that is anticipated as a result of participation in the actvity by completing the apporpriate sentence below:

    • Professional Practice Gap and Learner Objective #4

    • Desired Outcome #4

      Indicate a measureable change that is anticipated as a result of participation in the activity by completing the appropriate sentence below:

    • Educational Content

      Activities should be designed to support desirable physician attributes and core competencies, as published by the Institute of Medicine, the Medical Specialty Boards and the ACGME.  Additionally, these and other national bodies have identified patient safety issues as being critical to the quality of medical care in the United States.  Planners should make certain that content addresses quality and/or patient safety issues, whenever applicable.

    • Teaching Methods

    • Faculty

      Please list name, credentials and contact information.

    • Additional Faculty (click on arrow to add more faculty)  
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    • Agenda


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    • Funding

    • Draft Budget

    • Faculty Expense

    • Venue Expense

    • Other Expenses

    • Income

    • Promotional Method

      Draft promotional materials and any handout/syllabus must be submitted at least 30 days prior to publication for approval of ACCME elements.

    • Educational Outcomes Measurement

      The purpose of CME is to bring change in behavior through increased competency (knowledge put into action by the learner), increased performance (competency put into action) and improved patient outcomes.

    • A Final Report is due  within 30 days of activity to include:

      ·       Completed sign-in sheets

      ·       List of attendees indicating physicians and non-physicians and their specialties, email address, and office/home address

      ·       Evaluation summary

      ·       Final budget

      ·       Final copy of all on-site and promotional materials

    • I have carefully read and considered each item in this form, and have completed it to the best of my ability.

    • Thank you for making application for Joint Sponsorship of your educational activity.  Notice of our decision to accredit will be emailed to the program Activity Director within thirty (30) days. 

    • Copyright © 2011 by Medicus, Inc. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form (electronic, mechanical, photocopying, recording or otherwise) without prior written permission from the publisher.

      Permission requests to photocopy portions for internal or personal use or to reprint this text in part or in whole for noncommercial uses must be submitted in writing to the publisher.

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