Speaker Activity Development and Faculty Form: Including Practice Gap (CE)

Divison of Continuing Education
Speaker Activity and Practice Gap Form

"To teach is to learn twice over" ~ Joseph Jourbert
If you have any questions while completing this form, please refer to the Faculty Guidance Packet (click here) or contact Megan McNeal at megan.mcneal@st-claire.org or 606-783-7578. Powerpoint presentation slides will need to be presented at least two weeks prior to your presentation date. Slides must include disclosure statement. See examples here.
Presenter Information:
Name:*

First NameLast Name
Credentials:*
Job Title:*
Affiliation:*
Employer/Company/Etc.
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
If you would like to designate a point of contact, do so here:
Name:

First NameLast Name
Email:
example@example.com
Phone Number:
Please enter a valid phone number.

Short Biography (to be published in materials, a CV or resume must be submitted separately and may be attached below): If you want us to introduce you, this is what we will go by!*
Professional Headshot

This will be used in the CE flyer or brochure.
Please upload a CV or resume:*

Cancelof

Activity Information
Proposed Activity Title:*
Proposed Date(s)*
Proposed Time(s)*
Type of Activity (See Faculty Guidance Packet and choose one. Activity type should coordinate with learning objectives and activity learning methods.)*

Competency/Knowledge-based activityApplication/Practice-based activity
Overall Activity Learning Objectives*
(ACCME Criteria 2, 3, 11)
- Please list at least 3 objectives for your presentation.
- Objectives should be specific, measurable, and align with Bloom's Taxonomy for action verbs).
- For Competency/Knowledge-based activities, please see the Bloom's Taxonomy verbs found HERE.
- Note: What is the overall program learning objectives that will address the identified professional practice gap?
Overall Activity Learning Objectives*
(ACCME Criteria 2, 3, 11)
- Please list at least 3 objectives for your presentation.
- Objectives should be specific, measurable, and align with Bloom's Taxonomy for action verbs).
- For Application/Practice-based activities, please the Bloom's Taxonomy verbs found HERE.
- Note: What is the overall program learning objectives that will address the identified professional practice gap?
Please list at least three objectives here: *
After attending the program, participants will be able to...

Practice Gap

Click HERE to see an example of a Practice Gap Analysis.
Current Practice

What are medical professionals NOT doing? What do they need to be aware of? Why are they not aware of it?
Answer*
Desired Practice

What do you want to happen? What SHOULD medical professionals be doing that they aren't currently?
Answer:*
Practice Gap

The practice gap includes both of the above statements, e.g., "Physicians are not aware of X due to Y. To fill this gap, physicians need to improve their knowledge of Z to achieve optimal patient care."
Answer:*
Gap Due to:
What knowledge or practice is missing that needs to be addressed?

KnowledgePracticeApplication

Conflict of Interest Resolution

If speakers are found to have a financial relationship when completing the Speaker Disclosure form, the Northeast Kentucky Area Health Education Center will follow appropriate steps to ensure a conflict of interest does not intrude upon the education content of the continuing education program. The NE KY AHEC, by either the Continuing Education Coordinator or their designee, will complete the following steps:
1. Identify the conflict of interest as documented in the speaker disclosure form and documents that the conflict has been addressed.
2. Contact the speaker(s) to discuss the definition of a Conflict of Interest as defined in the policy on the Speaker Disclosure form.
3. The speaker will be required to submit their presentation slides at least 7 days prior to the activity, so that the committee can look over approve it is free of any commercial bias.
- In order to meet accreditation requirements regarding potential conflicts, speakers must adhere to the following requirements:
  Any recommendations involving clinical medicine must be based on evidence accepted within the medical profession as appropriate for the care of patients.
- Research reported or referred to should conform to accepted standards
- Content should promote improvements in quality of care and not a specific business or ineligible company.
- A balanced view of therapeutic options should be given, along with generic names to provide impartiality.
- Educational materials can't contain any advertising, trade names or produced messages.

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.
GUIDANCE FOR PLANNERS,FACULTY AND OTHERS TO ENSURE CLINICAL CONTENT IS VALID
Should be Empty:

Speaker Activity and Practice Gap Form

Professional Headshot

Current Practice

Desired Practice

Practice Gap

Gap Due to: