TMA CME Application

JOINT PROVIDERSHIP ACTIVITY APPLICATION

TNMED.ORG/CME
This document collects all information necessary to plan and have your proposed educational activity certified for AMA PRA Category 1 Credit(s)™. Completion of the entire form is necessary to meet accreditation requirements and be approved for continuing education credit. Submit your application several months prior to your planned activity to ensure proper planning and coordination, and to have the time you need to promote your activity once accreditation has been approved. A live, either in person or internet, your accredidation will be active for one year. If enduring/on demand, it will be active for three years.

Tennessee Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
Date Submitted*

MonthDayYear
Date
Company/Orgniazation Name*
Please provide a brief description of your organization's purpose or mission.
Proposed Activity Information
Activity Type *

In-Person Live CourseInternet LiveInternet Enduring (On Demand)Regularly Scheduled Series (RSS)/Grand RoundsOther (explain)
Activity Title*
Purpose Statement *
If live (in person or on demand), what are the activity date(s):
Begin*

MonthDayYear
Date
End*

MonthDayYear
Date
Frequency of Program/Activity*

One TimeWeeklyMonthlyQuarterlyEnduring/On DemandOther
Hours of total instruction*
Hours AMA PRA Category 1 Credit(s) to be offered*
Medical Activity/Course Director (MD or DO)

The physician with overall responsibility for ensuring this activity is educational for the target audience and that the planning, developing, and implementation are in accordance with CME policies.
Name*

First NameLast Name
MDDO
Email*
example@example.com
Program/Activity Coordinator.

The Program/Activity Coordinator is the individual responsible for the operational, logistical and administrative coordination of the certified CME activity.
Name*

First NameLast Name
Email*
example@example.com
Content and Design
According to the ACCME, CME must be:
- Designed specifically for physicians or medical professionals
- Unbiased by Commercial Interests
- Educational
- Evidence-Based
- Free from Promotion
CME activities must be designed and directed to serve the clinical and professional performance of practicing physicians. What is the target audience for this activity? (Please check all that apply)*

PhysiciansNurse/Nurse PractitionersAllied Health ProfessionalsMedical StudentsOther
Please explain how this CME activity will align with TMA CME Mission Statement
Professional Practice Gaps

A professional practice gap is the difference between current practice and optimal practice. It can also be described as the difference between what actually occurs and what should occur to give the best possible care to patients. CME is intended to be designed to address gaps in knowledge, competence or performance.
Professional Practice Gaps

A professional practice gap is the difference between current practice and optimal practice. It can also be described as the difference between what actually occurs and what should occur to give the best possible care to patients. CME is intended to be designed to address gaps in knowledge, competence or performance.
State the professional practice gap(s) of your learners on which the activity was based. (maximum 100 words)*
State the educational need(s) that you determined to be the cause of your professional practice gap/problem(s) The needs will help you determine your learning objectives. If you have knowledge or competency needs your learning objectives should be competency based and if your needs are performance based, then the learning objectives should be performance based.
Knowledge/Competency Based Need(s)
Performance Based Need(s)
State what this CME activity was designed to change in terms of learner’s competence or performance or patient outcomes. (Please check all that apply)*

CompetencePerformancePatient Outcomes
Explanation (maximum 50 word explanation)
Indicate the desired results/attribute(s) (i.e., competencies) this activity addresses. The ACCME requires us to report how the CME activity is designed in context of desirable physician attributes. Which desired physician attributes from the below list will your activity meet? (Please check all that apply)*

Medical KnowledgePractice-Based Learning and ImprovementInterpersonal and Communication SkillsProfessionalismSystems-Based PracticeProvide patient-centered care
Other Competencies

Please check if competencies other than those listed will be addressed
Please list additional competencies
Please provide a description of how you will ensure content validity (peer review of materials, instructions to the faculty and planners, etc.) Trade names should not be used in any accredited CME/CE materials and no activity should promote the interests of ineligible companies.

(ACCME Standards for Integrity and Independence in Accredited Continuing Education)
Educational Format: How will the CME activity be designed to facilitate a change in the learners? Adult learning principles and the physician learning and change process should be considered when selecting the appropriate method. (please check all that apply)*

LectureCase StudySmall Group DiscussionsPanel DiscussionEnduring (On-Demand) MaterialsSimulationsObserving a procedureHands-on WorkshopTake away messages (summaries, best practices)Other
Explain why this educational format is appropriate for the activity. (maximum 25 words)*
Potential barriers that may prevent learners from achieving desired results. These may be perceived or real barriers preventing the learners from achieving expected changes in competence, performance or patient outcomes. (Please check all that apply)*

Lack of time to assess or counsel patientsLack of consensus on professional guidelinesLack of administrative support/resourcesInsurance/reimbursement issuesCostPatient adherence issuesNo barriersOther
Please explain how you will try to address potential barriers with this CME activity
Course Objectives. Based on your identified educational needs, what are the objectives and/or the purpose of this activity? Your objectives should be measurable and state specific improvements or tasks your learners should be able to do as a result of what they learn from this activity (specific outcomes).

The number of objectives is not as important as the accuracy of intended outcomes. List objectives and describe each in the space provided. Please use verbs for writing operational/behavioral objectives.

Reference Documents:

Bloom’s Taxonomy Verb List
At the end of this activity participants should be able to:
At the end of this activity participants should be able to:
At the end of this activity participants should be able to:
At the end of this activity participants should be able to:
At the end of this activity participants should be able to:
Are there strategies that could be used to enhance change in your learners as an adjunct to this activity? Examples include patient surveys, patient information packets, email reminders to the learners i.e., summary points from the lecture, new information, posters throughout the hospital, pocket guides)*
You are required to measure the outcomes of this educational activity. Evaluations are a tool used to determine if the desired educational results were achieved and objectives met for the learners. Only one form of evaluation is required. Evaluation tool should clearly list the name of the activity, speaker(s), and objectives. Please check the methods of outcome measurement that will be used to measure change in the learners’ knowledge, competence, performance or patient outcomes. TMA can provide an online evaluation template.

Online Evaluation SurveyWritten EvaluationPost Conference Evaluation Follow-up (4-6 weeks)Pre-testPost-testQuality DataOther
Activity Planners and Speakers
Planners and Speakers List. On a seperate document, please provide a list of the names and roles/affiliations of all individuals (planners and speakers) for this activity and provide to TMA staff a CV, bio or resume for each. This includes the activity medical director and coordinator, planning committee members, and anyone in a position of control or influence over the planning, speaker selection, topic selection, content, agenda, evaluation, etc. for this educational activity. This list will also serve as a checklist for providing additional information for planners and speakers referenced later in the application.
If any speaker is receiving an honorarium for their participation, include proposed amount. All honorariums must comply with TMA Policy on CME Honorarium.
Are proposed honoraria within policy requirements established by TMA?

YesNoN/A
Disclosure Forms: The ACCME requires that anyone who has the opportunity to influence the content of the CME activity disclose any and all financial relationships (or the lack thereof) they or their significant other has with a commercial interest; and that any potential conflicts of interest be resolved before the activity occurs.

The course director, planning committee members, staff, speakers, authors, moderators, etc, must complete a Disclosure Form. Disclosure forms for speakers not yet identified and/ or confirmed must be submitted at least 1 week prior to activity start date.

Conflict of Interest Resolution (COI): If a conflict of commercial interest is identified, TMA CME staff will reach out to discuss any needed actions (i.e. presentation slide review, etc

Disclosure to Learners Statement: The ACCME requires that disclosure of all financial relationships (or the lack thereof) for anyone who has control over CME content is communicated to the CME audience prior to or during the activity. The TMA will provide the Disclosure to Learners document once all speaker and planner disclosures are reviewed.

Detailed Activity Agenda: Please submit an activity schedule/agenda showing all sessions (CME and non-CME) with exact start and end times provided for each topic/presentation or activity including method of instruction and name of speaker(s) for each. Include any planned break times during or between sessions, and any related social events.
Event Financials
Will a registration fee be charged?*

YesNo
If yes, please specify amount
Do you plan to seek educational grant(s) for this activity?*

YesNo
If yes, please specify companies you will be applying for and the amount of each request.
As a part of your closing activity report, you will be asked to submit basic financial information which includes:

1. Total advertising and exhibit income received in support of your Program

2. Total registration fees received (includes registration, subscription or publication fees received from activity learners)

3. Total government monetary grants received (monetary grants received from federal, state, or local governmental agencies in support of your Program)

4. Total private monetary donations received (monetary donations received from the private sector, including foundations, in support of your Program)
Disclosing Commercial Support

Commercial support is monetary or in-kind contributions from a commercial interest that is used to fund all or part of the costs of your CME activity. (Commercial interest is an entity that produces, markets, re-sells, or distributes health care goods or services consumed by or used on patients)

The fees paid by commercial interest to providers for exhibits and advertisements are not considered to be commercial support, however providers must meet certain requirements if commercial exhibits or advertisements directly accompany CME programing.
Is there any possibility that this activity will receive support from any commercial interest(s) during this approval period?*

YesNoNot certain
Commercial Support Letters of Agreement (LOA): The ACCME requires a LOA for Commercial Support for all educational grants received from a commercial interest to support CME. LOA’s must be signed by the company’s representative and the CME Provider and/or, in some cases, the joint sponsor/educational partner, if applicable. Signed copies of all LOA’s must be maintained in the CME Department. If needed TMA will provide LOA.

Management of Commercial Support: The ACCME requires that all commercial support be appropriately managed by the CME Provider. A financial budget statement is required for each activity where commercial support is received. The budget information must be submitted at the conclusion of the activity.

Acknowledgement of Commercial Support: The ACCME requires that all commercial support be acknowledged to the CME audience prior to the activity.

Enduring/On-Demand Materials. Enduring materials have additional requirements. Access to bibliographic resources for further study must be made available. The course review date, original release date, and termination date must be included on the enduring material. Enduring materials must be reviewed at least every three years. For enduring activities, TMA CME staff will contact you regarding additional guidelines and requirements. Please let the TMA know if you plan to use this material as enduring programing.
Marketing and Promotion
How will you market or promote this activity to potential participants? Check all that apply*

Save-the-Date Announcement Brochure/Flyer or HandoutInvitationOnline or Print NewsletterWebpageEmailOnline or Print AdvertisementOther
Approval of Promotional Materials. TMA’s CME Office must review and approve all materials associated with the activity prior to having them produced and distributed. ACCME/AMA will allow simple save-the-date announcements to be mailed prior to CME designation provided CME is not mentioned. The phrases “CME has been applied for” or “CME is pending” are not allowed. Any other promotion (website, press release, newsletter, etc cannot mention CME until TMA has approved this activity for CME/AMA credits.

The AMA accreditation statement and the TMA Logo must be included on all promotional materials with the exception of simple save-the-date announcements, as mentioned previously.

Materials Content. Marketing materials must include contain the accrediation stament and TMA identified as the sponsor. To the best of design efforts we recommend also including learning objectives, program faculty and presenters, agenda and sources of financial support.
CME Certificates and Activity Closeout
An Activity Closeout Report must be completed at the completion of this activity. CME certificates will not be issued until all documentation is complete for both this application and the close out report. The closeout report includes total hours of CME provided through the activity, participation data, content confirmation, information regarding prescribing education (if applicable), disclosure forms, documentation of disclosure statements, financial data (including information related to commercial support, if applicable)
I understand and agree to the terms set by the requirements in this agreement for AMA PRA Category 1 Credit™
Printed name*
Signature (Program Director)*

Clear
Date*

MonthDayYear
Date
I understand that within 30 days after completion of the activity, all post-activity paperwork must be submitted to the TMA Office of CME, and that certificates for CME and attendance will not be distributed until after the Closeout Report is submitted and documentation is complete.
Printed name*
Signature (Conference Coordinator)*

Clear
Date*

MonthDayYear
Date
Should be Empty:

JOINT PROVIDERSHIP ACTIVITY APPLICATION

Proposed Activity Information

If live (in person or on demand), what are the activity date(s):

Medical Activity/Course Director (MD or DO)​

Program/Activity Coordinator. ​

Content and Design

Professional Practice Gaps

Activity Planners and Speakers

Event Financials

Marketing and Promotion

CME Certificates and Activity Closeout

Medical Activity/Course Director (MD or DO)

Program/Activity Coordinator.