Application for Joint Providership for Continuing Educational Activities

Application for Joint Providership
Thank you for seeking joint providership from the American College of Occupational and Environmental Medicine (ACOEM)!

Joint providership of CME activities carries with it the obligation to comply with all of ACCME’s requirements and ACOEM's Joint Providership Guidelines. Failure to follow these requirements can jeopardize ACOEM’s accreditation status with ACCME. It will be beneficial to review these documents prior to completing the application.

Please note that you must complete the application in one sitting. Progress cannot be saved.

Applications for provisional approval should be submitted at least six months in advance of the activity. An additional fee may apply if the application is submitted in less than six months prior.

Questions? Contact jointprovider@acoem.org or call 847-818-1800.

Joint Providership Fees
Fees are not refundable once joint providership is granted. Should providership not be granted, fees paid by ACOEM Components are fully refundable while outside entity fees are refundable minus a handling fee of $250. Fees will be invoiced via email upon receipt of application. Online payment is due within 7 days of invoice.

ACOEM Component Society
Joint Providership Administration Fee: $500
CME Credit Fee: Not Applicable

ACOEM Special Interest Section
Joint Providership Administration Fee: Not Applicable
CME Credit Fee: Not Applicable

Non-ACOEM Component or Section (Outside Entity)
Joint Providership Administration Fee: $750
CME Credit Fee:
1 - 10.75 Credits: $1,000
11 - 20.75 Credits: $1,250
21+ Credits: $1,500

Applicant Information
Organization Applying for Joint Providership*
Primary Contact*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number

Activity Overview
Activity Title*
Type of Activity*
Brief Overview of Activity*
Requested CME Hours*
If unknown, please provide estimate.
Activity Location (City/State)*
(if not applicable, enter N/A)
Activity Start Date*

MonthDayYear
Date
Activity End Date*

MonthDayYear
Date

Commercial Support
ACOEM is committed to presenting CME activities that (1) present learners with only accurate, balanced, scientifically justified recommendations, and (2) protect learners from promotion, marketing, and commercial bias. As part of this commitment, ACOEM has outlined in a written agreement the terms, conditions, and purposes of commercial support for its CME activities (referred to as the "Letter of Agreement (LOA)". Commercial Support is defined as financial, or in-kind, contributions given by a ineligible companies[*], which is used to pay all or part of the costs of a CME activity.

[*]The ACCME defines an ineligible company as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. The ACCME does not consider providers of clinical service directly to patients to be ineligible companies. For more information, visit www.accme.org.

If commercial support is being accepted for this activity, ACOEM's Letter of Agreement (LOA) must be completed for EACH instance. Download the LOA form from this page, and send completed forms to ACOEM staff at jointprovider@acoem.org.
Do you anticipate COMMERCIAL SUPPORT being accepted for this activity? If yes, you will be required to provide fully executed Letters of Agreement along with a final budget to jointprovider@acoem.org.*

NoYes

Knowledge/Practice Gaps
Knowledge/practice gaps are the difference between what the learner should be doing in practice or should know and what they actually do in practice or actually know.

Please Note: Gaps are not learning objectives, agenda items, or descriptions of your program. Therefore, please do not list that information below. Only the activity’s education gaps should be listed.

Example 1 (A good example for an annual conference): The field of occupational and environment medicine is evolving at a rapid pace. Annual updates on the latest research, standards of care, and treatment options are needed for individuals to practice.

Example 2: Recent government regulations have changed the way physicians need to (insert text). However, there is currently little to no information available about the new regulations, making it difficult to be in compliance.
List Knowledge/Practice Gaps (Limit 100 Words) *

0/100
What is the educational need that you determined to be the cause of the gap? (please note that most will fall under knowledge and competence)*

Knowledge need (learners need new information)Competence need (learners need practical strategies)Performance need (learners need guidance, feedback and hands-on training)
State the educational need(s) that you determined to be the cause of the professional practice gap(s).*

Learning Objectives
Provide at least three objectives for the activity using active verbs.

How to write Learning Objectives
At the conclusion of this activity, learners should be able to:*
This activity is designed to change (check all that apply and note that most will fall under competence since it is difficult to measure performance and patient outcomes):*

Competence (the ability to apply knowledge, skills and judgment in practice)Performance (what one actually does in practice; you will need to go back to learners to determine if they made a change in their practice)Patient Outcomes (measurable results of treatment; must have access to this data to determine if the activity made a difference)
How will this change be measured? (Limit 50 Words) *Please note that competence can be measured by asking the question, "What do you plan to change in your practice as a result of attending this activity?" Performance can really only be measured by watching the learner do something or by going back to them to ask if they made a change after the activity, and patient outcomes are difficult to determine unless there is access to patient data.*

0/50
Please choose the reason below why this educational format is appropriate for this activity.*

A live course format allows for the presentation of a large amount of content to be delivered over several days.A webinar allows for niche topics to be delivered in a short amount of time to a wide audience.Other

Faculty and Planning Committee
It is very important to remember that employees or owners of ACCME-defined ineligible companies. cannot control CME content for CME activities (e.g., participate as planners, reviewers, faculty, authors, and/or others who control educational content). If you have employees of an ACCME-defined ineligible company as faculty or planners, please contact ACOEM in advance to discuss.

Planning Committee members must disclose prior to the start of developing the program. The only way to resolve disclosures for the planning committee is to remind them during the first planning meeting that if they have any conflicts during any discussion to recuse themselves. Please remind your planning committee of this.

Disclosure information must be obtained from all faculty/moderators and program planning committee members, using ACOEM's Disclosure Form.
Planning Committee Members*
You may upload Planning Committee Member disclosure forms here or submit them to ACOEM staff as you collect them. Please remember that ACOEM must have all disclosures in order to provide final approval of CME.

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Faculty/Moderator Information*
You may upload Faculty/Moderator disclosure forms here or submit them to ACOEM staff as you collect them. Please remember that ACOEM must have all disclosures in order to provide final approval of CME.

Browse Files

Cancelof

Program Agenda
Upload the hour-by-hour program agenda if available at this time. Please remember that ACOEM must have a final, complete agenda in order to determine the final CME count and to provide final approval. (Word or PDF)

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Additional comments regarding your activity:

Acknowledgement and Signature
Should you receive provisional approval of your application, ACOEM will guide you on how to meet the following requirements:
- Applicants for joint providership must agree to comply with the ACCME’s requirements, in particular the Standards for Integrity and Independence in Accredited Continuing Education, and ACOEM's Joint Providership Guidelines. Failure to do so may result in revocation of approval.
- All activity promotion and recruiting materials, emails, advertisements must be reviewed and approved by ACOEM before distribution to potential participants.
- Peer review for clinical accuracy and commercial bias are required for all educational content, either directly by ACOEM or through a physician member of the program planning committee.
- A comprehensive list of all materials needed, including on-site and post activity requirements, will be sent to you should your application be provisionally approved.
- A Credit Claim Form will be provided to you at notification of approval. The form MUST be completed by the submitter post-event and sent to ACOEM at jointprovider@acoem.org for CME to be processed.
USE YOUR CURSOR OR FINGER TO SIGN IN THE BOX. By signing below, I am attesting that the aforementioned information is accurate to the best of my knowledge. As a representative of the submitting organization, I agree to pay the stated fees and comply with ACCME's requirements and ACOEM's Joint Providership Guidelines.*

Clear
Typed Name of Signatory *
Date and Time Submitted
Should be Empty: