ACMG CME Application

Education Activity Application

This form attempts to collect all information necessary to plan and develop the proposed educational activity. Completion of all sections of this form is necessary to meet accreditation requirements. ACMG Education team is available to help you navigate this process.
Activity Information
Please Complete the information below*
Activity Date

MonthDayYear
Date
Activity Director (AD)
The physician or basic scientist who has overall responsibility for planning, developing, implementing, and evaluating the content and logistics of a certified activity.*
The American College of Medical Genetics and Genomics (ACMG) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. As part of this accreditation, we are able to provide CME activities for working units/internal stakeholders of ACMG.
What type of credits are you interested in providing? *
Planning Process C7
1. Who identified the speakers and topics*
2. What criteria were used in the selection of speakers (select all that apply)?*
3. Were any employees of a pharmaceutical company and/or medical device manufacturer involved with the identification of speakers and/or topics?*

NoYes, please explain:
Desirable Physician Attributes / Core Competencies (select 1 at minimum) C6
CME activities should be developed in the context of desirable physician attributes. Place a “✅" next to all American Board of Medical Specialties (ABMS)/Accreditation Council for Graduate Medical Education (ACGME) or Institute of Medicine (IOM) core competencies that will be addressed in this activity.*

Employ evidence-based practiceInterdisciplinary teamsInterpersonal and communication skillsMedical knowledgePatient care or patient-centered carePractice-based learning and improvementProfessionalismQuality improvementSystem-based practiceUtilize informatics
Needs Assessment Data and Sources (select 2 at minimum) C2
Please indicate how the need for this activity was brought to your attention. Select all that apply and provide supportive documentation for all boxes checked. If you cannot provide documentation, do NOT check that source.

Continuing review of changes in quality of care as revealed by medical audit or other patient care reviews. Potential sources of documentation: audit reports, chart reviewsOngoing census of diagnoses made by physicians on staff. Potential sources of documentation: summary of notes, minutes of meetingsAdvice from authorities of the field or relevant medical societies. Potential sources of documentation: list of expert names/medical societies AND summary of recommendation(s)Formal or informal requests or surveys of the target audience, faculty or staff. Potential sources of documentation: summary of requests or surveys. Note, must show information related to areas of education need/topics of interest (not logistical summaries – i.e., food, venue, etc)Discussion in departmental meetings. Potential sources of documentation: summary of meeting minutes showing information discussed was related to areas of education need/topics of interest (not logistical summaries – i.e., food, venue, etc)Data from peer-reviewed journals, government sources, consensus reports. Potential sources of documentation: abstracts/full journal articles, government produced documents describing educational need and physician practice gaps.Review of board examinations and/or re-certification requirements. Potential sources of documentation: board review/update requirements.New technology, methods of diagnosis/treatment. Potential sources of documentation: description of new procedure, technology, treatment, etc.Legislative, regulatory or organizational changes affecting patientcare. Potential sources of documentation: copy of the measure/change.Joint Commission Patient Safety Goal/Competency. Potential sources of documentation: copy of the safety goal and/or competency.Other
Identification of Professional Practice Gaps, Educational Needs, Learning Objectives, and Desired Results (minimum of 2 total must be identified for the overall activity) C2, C3
1. A professional practice gap is defined as the difference between ACTUAL (what is) and IDEAL (what should be) in regards to performance and/or patient outcomes.
2. An educational need is defined as “the need for education on a specific topic identified by a gap in professional practice.”
3. Learning objectives are the take-home messages; what should the learner be able to accomplish after the activity? Objectives should bridge the gap between the identified need/gap and the desired result.
4. Desired results are what you expect the learner to do in his/her practice setting. How will the information presented impact the clinical practice and/or behavior of the learner? Indicate how this change could be reasonably measured.
5. Competence is defined as the ability to apply knowledge, skills, and judgment in practice (knowing how to do something).
6. Performance is defined as what one actual does, in practice.
Note: Identification of gaps, needs, etc. should be completed by the Activity Director.*
Education Design/Methodology C5
Please indicate the educational method(s) that will be used to achieve the stated goals and objectives. Select all that apply by placing a “✅" in the appropriate box.*

Case presentationsDidactic lectureEnduring MaterialPanel discussionsQ&A sessionsRoundtable discussionsSimulation/skills labsOther, specify:
Course Description:
Target Audience:
Writing Learning Objectives
For Continuing Education Activities – Learn More here NSGC guidelines

Acceptable Verbs for Writing Objectives

An active learning strategy to engage the audience in the content is included for each objective. Each objective includes a learning assessment method for participants to evaluate their mastery of content and learning. Continue reading below for help on writing measurable learning objectives. Accreditation requirements submitted for educational credits must contain:

· 1 Learning Objective per 30 session minutes (includes panels)

· 1 Learning Objective per presentation

Example: 90-minute session with 4 Presenters requires 4 learning objectives

*Only ONE behavioral verb must be used per objective.

The following is a list of suggested verbs which may be used in the development of our objectives. The 2001 revision of Bloom’s Taxonomy classifies measurable verbs into hierarchical levels, as shown below. This list is not meant to be all inclusive and limiting. Used properly, these behavioral verbs will be found acceptable.

*Only ONE behavioral verb must be used per objective.

Words that are NOT measurable and should not be used (i.e., know, grasp the significance of, have knowledge of, comprehend, think, be aware of, remember, perceive, understand, appreciate, learn).
Learning Objective 1*
Learning Objective 2*
Learning Objective 3*
Add more learning objectives
Attached agenda: See Example here.
Agenda*

Cancelof
Presenter(s): In alpha order*

Education Activity Application

Attached agenda: See Example here.