NKCH 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 being awarded for the activity.
ACTIVITY INFORMATION
Title of Continuing Medical Education Activity:
*
Cardio Noon Grand Round
Other
Date of Activity:
*
-
Month
-
Day
Year
Date
If this activity has multiple formats, please defined type of activity for specified date:
*
Grand Round
Journal Club
Case Conference
M&M
Activity Coordinator Name:
*
First Name
Last Name
Activity Coordinator E-Mail:
*
example@example.com
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PRIOR TO ACTIVITY
1. Advance notice provided for activity (E-mail notification, flyer, electronic announcement...)
*
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. Credit Claim Form updated and reflects the appropriate speaker/moderator and date of the activity?
*
Yes
No (If no, please contact INMED for updated Credit Claim Form)
3. Conflict of Interest/Disclosure information has been submitted to INMED for speaker/case presenter/moderator within the required time frame?
*
Yes
No
4. Free From Commercial Support Influence? (No industry representative had any input into the preparation of this activity.)
*
Yes
No
If No, please explain:
5. Free from Third-Party financial or in-kind support (including food)?
*
Yes
No
If No, please explain:
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DURING THE ACTIVITY
6. Conflict of Interest/Disclosure information is listed on the Credit Claim Form for:
*
Planners/Planning Committee
Moderator
Speaker/Faculty
7. Credit Claim Form:
*
Accreditation Statement and Disclosures are made available in writing to all attendees
Attendees sign name in appropriate box
Attendees indicate if they desire Accredited Continuing Education Credit(s) or none
Attendees complete/verify or update e-mail address as needed
Attendees claim time commensurate for participation in the activity
N/A: Credit Claimed Online by all participants
8. EDUCATIONAL REPORTING (Only for Tumor Boards, Case Conferences, and M&M Activities)
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:
*
Upload Meeting Minutes (optional):
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POST ACTIVITY
9. Submit the following to INMED within 30 days of activity. The Check-list and Credit Claim Form must be submitted at the same time to receive credit.
*
Completed Check-List (this form)
Credit Claim Form
Upload completed activity Credit Claim Form.
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You can also upload additional documents here. Maximum of 3 files.
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Questions?
Contact CME@inmedce.com or call 816-444-6400 x3.
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