ASA Joint Providership Application
Please complete this form and submit your application fee. Applications without payment will not be considered.
Submitted by
*
First Name
Last Name
Organization
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Activity Name
*
Location
*
City, State or online
Back
Next
Activity Dates
*
Length of program- do not include days without CME programming
Planning committee: (List all Individuals who have influence over meeting content)
Attendees
*
How many participants do you expect?
Type of Activity
*
Course
Enduring Material
Internet Enduring Material
Journal CME
Manuscript Review
Test Item Writing
Please indicate the type(s) of credits you wish to offer:
*
CME credit
MOCA Part 2 - Patient Safety
MOCA Part 4 - Quality Improvement
Educational Needs
Professional Practice Gap
*
What problem(s) need to be fixed? What are practitioners doing or not doing in practice that is less than optimal? (100 words max)
0/100
Describe the educational need(s) that you determined to be the cause of the professional practice gap(s) (max. 50 words each). (C2) Knowledge factual information Competence knowing how to do something – e.g., strategies – not yet put into practice Performance implementing skills, abilities, or strategies in practice
*
Knowledge
Competence
Performance
Knowledge:
0/50
Competence:
0/50
Performance:
0/50
What, if any, Patient/Health Care Outcomes will this activity change as a consequence of changes in actual performance in practice?
0/50
Back
Next
Expected Results:
*
0/50
Format
*
0/50
Learning Objectives
*
0/75
Evaluation
*
0/50
Outcomes
Indicate which level of outcomes this program will measure. Most face-to-face meetings do not achieve above a level 3 outcome.
Participation Level 1 The number of healthcare professionals who participated in the activity or program. Satisfaction Level 2 The degree to which the expectations of the participants about the setting and delivery of the activity or program were met. Learning Learning Level 3a Learning: Declarative Knowledge The degree to which participants could demonstrate that they
know what
the activity intended for them to know. Level 3b Learning: Procedural Knowledge The degree to which participants could demonstrate that they
know how
to do what the activity intended for them to know how to do. Competence Level 4 The degree to which participants could
show
in an educational setting
how
to do what the activity intended them to be able to do. Performance Level 5 The degree to which participants could
do
what the activity intended them to be able to do. Patient Health Level 6 The degree to which the health status of patients improves due to changes in the practice behavior of participants. Community Health Level 7 The degree to which the health status of a community of patients changes due to changes in the practice behavior of participants.
Please indicate the outcome level.
*
Level 1
Level 2
Level 3a
Level 3b
Level 4
Level 5
Level 6
Level 7
Desirable Physician Attributes
Which desirable physician attributes (ACGME/ABMS/IOM Competencies) are addressed in the content of this activity? Check all that apply.
ACGME/ABMS Competencies
Patient Care and Procedural Skills
Medical Knowledge
Practice-based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Systems-based Practice
Institute of Medicine Competencies
Provide patient-centered care
Work in interdisciplinary teams
Employ evidence-based practice
Apply quality improvement
Utilize informatics
Interprofessional Education Collaborative Competencies
Values/Ethics for Interprofessional Practice
Roles/Responsibilities
Interprofessional Communication
Teams and Teamwork
Back
Next
Commercial Support
Please indicate if this activity is/will be receiving commercial support. Remember to include a signed LOA for each supporter.
Please indicate if this program will be receiving commercial support.
*
Yes
No
Type
Monetary Support
In-kind donations
Number of Commercial Supporters
How many Commercial Supporters will the program have.
Back
Next
Fees
Joint Providership Application Fee
$550.00
There is a one-time $550 Application Fee. Checks may be made payable to American Society of Anesthesiologists Send to: American Society of Anesthesiologists c/o Joseph Barnett Attn: Finance Department (JP Application Fee) 1061 American Lane Schaumburg, IL 60173
Please e-mail the program agenda for credit determination. The agenda can be preliminary.
Joint Providership Application Submission: By signing and submitting this application, you agree to abide by all ACCME and ASA requirements, enter into a joint providership relationship with ASA, the accredited provider, and carry out the respective responsibilities as outlined in the ASA Joint Providership - Program Description.
I Will Pay With:
Check
Signature and Date
Submit
Should be Empty: