CME Topic Request
Planning Form
Name of Planner
*
First Name
Last Name
Degree
Email
*
example@example.com
Role in Continuing Education
*
Please Select
Planner - Chair of Medical Education Committee
Planner - Member of Medical Education Committee
Planner - Other
Planner's Disclosures (If planner is not a Medical Education Committee Member)
*
Planner's Disclosure
- All Medical Education Committee Members disclosure's are noted here.
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Program Title 1
*
Program Title 2
*
Speaker Name 1
*
First Name
Last Name
Degree
Speaker Name 2
*
First Name
Last Name
Degree
Speaker Email 1
*
example@example.com
Speaker Email 2
*
example@example.com
Type of Program
*
Grand Rounds
Pediatric Grand Rounds
Special Event
Program Format
*
In Person
Live Internet via Zoom
Internet Enduring
Program Date
*
-
Month
-
Day
Year
Date
Length of Program
*
Please Select
30 Minutes
1 Hour
1 Hour and 30 Minutes
2 Hours
Will any of the time allotted for this program include non-educational time, such as lunches, dinner and/or breakfast breaks?
*
Yes
No
Will this activity be supported in any way by a commercial interest? This would include provision of meals?
*
Yes
No
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Practice-Based Problem (gap) Identification
*
MEC Discussion
Continuing Education Participation Evaluation
Department Chief
Quality Department
Other
What practice-based problem (gap) will this education address?
*
What is/are the reason(s) for the gap (barrier)? How are learners involved?
*
List Three Program Expectations
*
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What change(s) in strategy, performance, or patient care would you like this education to help learners accomplish?
*
Patient Care and Procedural Skill
Medical Knowledge
Practice Based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Provide Patient-Centered Care
Work in Interdisciplinary Teams
How will learners document their expected change(s) in strategy, performance, or patient care post program?
*
Survey/Evaluation with mandatory "two" new insights or concepts from program
Submit
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