CME Application Form

Activity Information:

Activity Title:

Type of CME Activity:

1. Who are the physician target audience for the CME activity?

2. What are the professional practice gaps/needs of the target audience that will be addressed?

3. Is it a gap in physician knowlegde, competence, or performance?

4. Based on the need/gap the activity is addressing, what is the activity designed to change?

Competence Performance Patient Outcomes

5. How were the needs/gaps identified by your department? check all that apply and ATTACH supporting documentation:
Expert Needs

Participant Needs:
Needs Assessment Survey of Target Audience (please provide summary)
Focus Panel Discussions/Interviews (please provide summary)
Previous Related Evaluation Summary (please provide summary)
Requested by affiliated institutions or physician groups:
Requests from physicians:

Observed Needs:
Adverse drug events:
Database analyses (e. g., RX changes, diagnosis trends, etc.):
Epidemiological data:
Hospital/Clinic QA analyses:
P&T or QI data/guidelines:
Mortality/morbidity data:
National clinic guidelines (NIH, NCI, AHRQ, etc):
Other clinical observances (specify):
Referral diagnosis data:
Speciality society guidelines (specify):

Environment:
American Board of Medical Specialties (AMBS)/Accreditation Council for Graduate Medical Education (ACGME) Competencies:

Healthy People 2010 Objectives
The Joint Commission Standards/Core Measures:
Laws/Regulations
Public Health Organizations (specify)
Other sociatal trends (specify)

6. What were the QA or PI measures associated with this activity?

7. Based on the desired results of the activity, list 3 to 5 overall learning objectives for this CME activity
1
2
3
4
5

8. What ACGME, ABMS or IOM related competency is associated with this activity?
Patient Care Medical /Clinical Knowledge Communication Skills
Professionalism System-based practice Practice based learning and improvement

9. The educational format(s) that best support the objectives of the activity is/are:
Listening fo expert faculty Interacting with faculty using Q&A or open discussion
Hands-on skills workshop Small group discussion
Simulation with real /or simulated patients Reading materials such as journals with open discussions or Q&A
Other:

10. How do you plan to evaluate the activity to determine its effectiveness at meeting the needs and creating change in competence, performance, or patient outcomes? (Evaluation of learners' change in competence, performance or patient outcomes is required)
Standard paper evaluation Post-course follow-up Survey Post-test Focus group
Practice data other

11. Describe process used to plan this activity and ATTACH minutes of planning committee meetings and disclosure forms for all members in attendance


12. Will you be using brochure and other promotional materials?  Yes No
Please provide a draft of the proposed save-the-date, flyers, and/or brochure with you applicationso that it can be approved prior to printing (Must have date of activity, topics, lecturer, objective of the topic, accrediditation, disclosures and ADA statements)

13: Budget:
Will a registration fee be charged?  No    Yes    If yes, How much?

14. Commercial Support:
Please indicate if this program will receive financial support from any commercial pharmaceutical companies or vendors?    Yes    No
if yes, what companies are you applying to:
CME disclosure, budget and commercial support forms can be downloaded from our website - www.downstate.edu/cme/applications.html

Signature: Activity Director Date:
Be sure to include the following with your application:
Application Fee (RSS $150 $350 joint) (Annual confrences $1500, other please call)
A completed and signed application
Signed Letter of Agreement (1st time activities only and all annual conferences)
Planning minutes
NEEDS DATA
A draft of you brochure or/and flyer
Priliminary Budget Plan
Evaluation form
CME Disclosure form(s)
Commercial Support form(s) (if applicable

Return the completed application and Make checks payable to SUNY OCME