Ascentist Continuing Medical Education Checklist
This mandatory form will assist you in planning, implementing and evaluating your activity. Failure to complete the form may result in no Continuing Medical Education credit being awarded for the activity.
ACTIVITY INFORMATION
Title of Continuing Medical Education Activity:
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ENT Physician Champion Grand Rounds
ENT M&M Conference
Date of Activity:
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Month
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Day
Year
Date
If this activity has multiple formats, please define the type of activity for the specified date:
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Grand Rounds
Journal Club
Case Conference
M&M
Activity Coordinator Name:
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First Name
Last Name
Activity Coordinator E-Mail:
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example@example.com
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PRIOR TO ACTIVITY
1. Did you provide advance notice for this Activity (E-mail notification, flyer, electronic announcement...)
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Yes (If yes, a copy must be approved by INMED prior to publication and distribution)
No
Please provide a copy of the notice provided for the activity. (A pdf of the email notification, flyer, electronic announcement, etc)
*
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2. Did INMED provide to you an updated Credit Claim Form and/or PowerPoint slide that reflects the Accreditation Statement, Learning Objectives, Speaker information and date of the Activity?
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Yes
No (If no, please contact INMED for updated Credit Claim Form)
3. Was a Disclosure Form submitted to INMED for the Speaker/Presenter within the required time frame?
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Yes
No
4. Was this Activity free from influence of Ineligible Companies? (No industry representative had any input into the preparation of this activity.)
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Yes
No
If No, please explain:
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5. Was this Activity free from Third-Party financial or in-kind support (including food)?
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Yes
No
If No, please explain:
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DURING THE ACTIVITY
6. Was Planning Committee and Speaker disclosure information made available to attendees and listed on the Credit Claim Form and/or PowerPoint slide prior to the Activity?
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Yes
No
7. Activity Format
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This Activity was Live (In-Person) Only
This Activity was both Live and Online/Virtual
This Activity was Online/Virtual Only
Upload completed activity Credit Claim Form, if applicable.
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You can also upload additional documents here. Maximum of 3 files.
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8. EDUCATIONAL REPORTING (Only for Case Conferences, M&M and Tumor Boards) Please upload Meeting Minutes/Agenda OR complete Questions 8a-8c.
Upload Meeting Minutes/Agenda:
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8-a Medical issue(s) captured as identified by specific case(s) selected:
8-b Outline of discussion (simple notes from meeting that does not include identifying patient information):
8-c Educational take-away point(s) from discussion of patient case(s), including adverse outcomes &/or death:
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Questions?
Contact CME@inmedce.com or call 816-444-6400 x3.
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