Activity Planning Form (CE)

Divison of Continuing Education
Activity Planning Form

If you have any questions while completing this form, contact Megan McNeal at megan.mcneal@st-claire.org or 606-783-7578.
Individual Submitting Request:
Name:*

First NameLast Name
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
Affiliation:*
Employer/Company/Etc.

Program Sponsor: Please indicate if this activity will be jointly provided by the Northeast Kentucky AHEC.*

Northeast KY AHEC providedJoint Providership
If the activity is a Joint Providership, please complete the Letter of Agreement, found here: https://form.jotform.com/211605436755052
If this activity is to be jointly provided, please indicate the joint entity requested: *

Follow up Outcomes Measurement
Your activity may be designed to measure change in performance and/or patient outcomes. If this is the case, consider establishing a baseline prior to the activity and measure the impact of your activity as it relates to change in learner performance, patient care, or overall health outcomes. Use the grid below to document this information. For joint-providership activities, establish follow-up dates/deadlines to obtain data.

Select your measurement type:

Rows	Measurement Type
Outcomes Measurement 1
Outcomes Measurement 2
Outcomes Measurement 3

Describe your measurement:

Rows	Describe your measurement
Outcomes Measurement 1
Outcomes Measurement 2
Outcomes Measurement 3

Select follow-up outcome time frame:

Rows	Follow-up outcomes data (select appropriate trime frame for follow-up)
Outcomes Measurement 1
Outcomes Measurement 2
Outcomes Measurement 3

Expected Results and Outcomes Measurement:

Rows	Enter text here
If your activity is designed to change competence, describe how you will measure intent to apply new strategies:
If your activity is designed to change performance, describe how you will measure changes in learner performance:
If your activity is designed to change patient outcomes, describe how you will measure changes in patient care and overall health outcomes.

Commerical Support

When activities have commerical support, it is required that all educational activities be developed indepenedntly of ineligilbe company. (ACCME Criteria 8, 9, 10)
Will this program receive commercial support?*

YesNo
If yes, please list the potential funding sources:
Will this education program have exhibits?*

YesNo
If yes, please list the potential exhibitors:
If there is commerical support, please refer to the following:
- A final list of supporters and exhibitors is required by the NE KY AHEC prior to the event.
- All supporters and providers must sign Letter of Agreement form prior to this event.
- If this event will have exhibitors, please refer to the NE AHEC Commercial Support and Disclosure.
Is this activity funded through any grant related source?*

YesNo
If yes, please specify:
Financial Projections

In order to be good stewards of all types of resources, projected expenses and revenue must be determined prior the activity and submitted to the NE AHEC Education Coordinator. Please utilize the Activity Budget form provided by the NE AHEC.
- The final budget for this education program is required
- All speaker honoraria and expenses are to be paid to the speaker by the Office of Continuing Medical Education. If paid by the educational partner, they must adhere to the Honorarium Policy.
Education Program Topics/Agenda

Once the agenda is finalized with session objectives, speakers, time and length of each presentation, please submit a completed agenda and corresponding Powerpoint presentation slides to Megan McNeal at NE KY AHEC (megan.mcneal@st-claire.org). Additionally, a CE Financial Disclosure form is required for each speaker prior to the activity.

Note: educational contact hours, are for actual instruction (including Q & A), it does not include welcome/introductions, breaks, meals, etc. Final determination of CME credit hours will be made after review of the agenda.

Note: The final agenda is required before a marketing brochure can be produced.

Collaboration - Engagement with the Enviornment

Occasionally there are stakeholders both internal (e.g. Patient safety, Quality, Research, Physician Practices) and/or external (e.g., KY Departments of Health, insurers, specialty societies, patient advocacy groups) working on similar healthcare issues with whome parterning to address these issues may assist in addressing barriers or provide resources. (ACCME Criteria 18, 19, 20, 21)
Are there entities within your healthcare organization working on the issues that are being addressed by this educational program?*

YesNo
List the entity(ies):*
If yes, will you include them in the development and/or execution of this educational program?*

YesNo
If no, why not?
Are there any external stakeholders working on the issues that are being addressed by this educational program?*

YesNo
If yes, list entity(ies):
If yes, will you be including them in the execution of this event?*

YesNo
If no, why not?

Faculty Selection (ACCME Criteria 7, 13)

Please indicate the profess for faculty selection for this education program.
Who identified the invited speaker(s)?*

Activity ChairNortheast Kentucky AHECPlanning CommitteeOther
If you selected other, please elaborate: *
What criteria will be used in the selection of the speaker(s)? (Select all that apply.)*

Excellence in teaching skillsPrevious experience as CME presenterSubject-matter expertOther
If you selected other, please elaborate: *
Speaker suggestions:
Name:

First NameLast Name
Organization/Affiliation:
Credentials:
Email:
example@example.com
Job Title:
Phone Number
Please enter a valid phone number.
Any other suggestions or requests relative to faculty?

Planning Committee (ACCME Criteria 7, 22)

Please list members of your planning committee. Each member must complete a CE Financial Disclosure Form, which identifies financial relationships. A completed CE Financial Disclosure Form for each individual member must accompany this application.
Activity Director/Coordinator

This individual is responsible for operational and administrative support of the activity; including completion of all required documentation and follow-up reporting.
Activity Director/Coordinator, Name:*

First NameLast Name
Activity Director/Coordinator, Email:*
example@example.com
Activity Director/Coordinator, Phone Number:*
Please enter a valid phone number.
Planning Committee Member 1, Name:

First NameLast Name
Planning Committee Member 1, Email:
example@example.com
Planning Committee Member 1, Phone Number:
Please enter a valid phone number.
Planning Committee Member 2, Name:

First NameLast Name
Planning Committee Member 2, Email:
example@example.com
Planning Committee Member 2, Phone Number:
Please enter a valid phone number.
Planning Committee Member 3, Name:

First NameLast Name
Planning Committee Member 3, Email:
example@example.com
Planning Committee Member 3, Phone Number:
Please enter a valid phone number.
Planning Committee Member 4, Name:

First NameLast Name
Planning Committee Member 4, Email:
example@example.com
Planning Committee Member 4, Phone Number:
Please enter a valid phone number.
Planning Committee Member 5, Name:

First NameLast Name
Planning Committee Member 5, Email:
example@example.com
Planning Committee Member 5, Phone Number:
Please enter a valid phone number.

You must complete a Disclosure of Financial Relationships form.
Click here to fill out the form.
By signing your name below, you are providing a signature attesting that all the information completed on this form is true and correct to the best of your knowledge: *

Clear
Date of signature: *

MonthDayYear
Date
For questions, please contact Megan Littleton at megan.mcneal@st-claire.org.
Should be Empty:

Activity Planning Form

Follow up Outcomes Measurement