CME Activity Application

Activity Information

Name of Activity:
Activity Course Director (Must be a Physician):
By taking on this role, you are agreeing to the Activity Director Roles and Responsibilities.
Activity Coordinator: By taking on this role, the Activity Coordinator is responsible for the operational, logistical, and administrative coordination of the certified CME activity.
Activity Type:
Live Session

Regularly Scheduled Series (RSS)

On Demand
Activity Date(s):
Activity Location:
Activity Frequency:
Weekly

Monthly

Twice a month

Quarterly

Yearly

One time

Other
Activity hours of instruction:

Who is the audience?
State the professional practice gap of your learners on which this activity is based (what is the problem you are trying to solve with this education?):
Identify the educational needs that apply to this activity (Select all that apply):
Knowledge: Goal is to move learners from "I don't know..." to "I know..." NOTE: For an activity to qualify for CME, it needs to address more than just knowledge.

Competence: Goal is skills-based. It's focused on knowledge in action - moving learners from "I don't know how..." to "I have a plan/strategy..."

Performance: Goal is to move learners from "I don't do..." to "I can do..." or "I am successful at..."
State the reason for the professional practice gap (why is there a problem?):
What are the learning objectives to address this problem? By the end of this education, learners will be able to... NOTE: We recommend educational activities have between 3-5 objectives. A single learning activity should not exceed 5 objectives. Consider revising the practice gap if more than 5 objectives are identified.
Is this an activity that you are interested in including MOC Points on as well as CME Credit? (specific to the following areas: Anesthesiology, Internal Medicine, Otolaryngology, Orthopedic Surgery, Pathology, Pediatrics and Surgery)
Yes

No

Maybe

Explain what competence, performance, or patient outcome this activity was designed to change:

Identify the format this activity is designed for:
Live Event (online or in person)

Enduring Material (podcast, interactive educational module, recorded presentation)

Journal-Based CME (peer reviewed article)

Test Item Writing

Manuscript Review

Identify the educational needs that apply to this activity (Select all that apply):
Patient Care and Procedural Skills

Medical Knowledge

Quality Improvement

Practice-Based Learning and Improvement

Interpersonal and Communication Skills

Professionalism

Systems-Based Practice

Provide Patient-Centered Care

Work in Interdisciplinary Teams

Employ Evidence-Based Practice

Utilize Informatics

Values/Ethics for Interprofessional Practice

Roles/Responsibilities

Interprofessional Communication

Teams and Teamwork

Describe the method used to obtain data or information about changes achieved in learners competence, performance or patient outcomes as a result of their participation in this activity. For example, quality improvement or patient outcomes.

Enter the names and roles/affiliations of all individuals (planners, speakers, authors, etc) for this activity. This will include the activity director, 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.
For an RSS or multi-session conference that may not have all speakers identified at the initial time of planning, a Speaker Form will need to be completed 1 week prior to their speaking date.

Indicate the method you will use to market/promote this event. Select all that apply:
Save the Date Announcement

Online/Print Newsletter

Brochure/Flyer/Handout

Webpage

Email Invitation

Email

Other

The CME Office will review and approve all promotional materials before they are distributed.