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Continuing Medical Education (CME)
PART 2: APPLICATION FOR A CME ACTIVITY
Please fill out this part 2 application form for the CME activity you are planning and submit it to the CME Office with all the necessary attachments.
You are only to complete this form once your part 1 Preliminary Application Proposal was completed and approved by the CME office.
Application For CME (Part 2) Summary
Date Submitted:
Did you complete PART 1 (Prelim App)?
Yes No
Activity Title:
Activity Director/Co-Director:
Activity Administrator:
CME office Section Comments:
Section E: Activity Education
Needs Assessment Collection (for overall CME activity): Select a minimum of 2 sources that indicate the need for this CME activity.
Data Sources
Expert faculty (e.g., planning committee, etc.)
Data from educational activity evaluations
Data from the peer-reviewed literature
Hospital Compare data
Healthy People 2020 Objectives
The Joint Commission Standards/Core Measures
Public Health Organizations (e.g., NIH, AHRQ)
Review of Board exams and or re-certification
National clinical guidelines
Medical record audit or patient care review
Other
Summarize very briefly BELOW the data from all checked boxes above of which you will be providing the source of documentation by attachments.
Did I provide/attach at least 2 sources of documentation?
CME Mission: Alignment with the our Mission Statement https://health.uconn.edu/continuing-medical-education/about-us/
How does this educational activity align with the CME office? (check all that apply)
Provides educational opportunities for individuals working in health care pursuing careers in the patient care professions, education, public health, biomedical and/or behavioral
sciences
Advances knowledge through basic, biomedical, clinical, behavioral, and social research
Develops, demonstrates, and delivers health care services based on effectiveness, efficiency, and the application of the latest advances in clinical and health care research
Helps health care professionals maintain their competence through continuing education programs
Barriers: What barriers do you anticipate your learners having when attempting to apply the new knowledge, competence, or performance learned
from this educational activity into their professional practices?
Cost
Lack of experience
Lack of opportunity (patients)
Lack of administrative support/resources
Lack of time to assess/counsel patients
Reimbursement/insurance issues
Lack of consensus or professional guidelines
Other:
Briefly describe BELOW how you will address these barriers in your educational activity.
Non-educational Strategies: After the conclusion of your educational activity, how will you implement non-educational strategies to reinforce the
educational goals of this program?
Office of Community & Continuing Medical Education
Email: [email protected]
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Reminders sent to the learner (i.e. email)
Program summary points from the lecture, new information
Peer review literature/follow-up articles
Newsletters
Other:
Building Bridges with Other Stakeholders: Please briefly identify BELOW other educational programs or initiatives taking place that are similar or
related to your CME educational activity. (These could be internal UConn Health sponsored or external such as Specialty Society, or Jackson Lab, etc.)
Could there be “potential” in future planning activities, these related/similar activities could be included in the development of this activity? If so, why
or why not.
Desirable Physician Attributes: check all that apply
ACME/ABMS Competencies
National Academy of Medicine Core Comp
Interprofessional Edu Collab Core Comp
ABMS Maintenance of Certification
Patient care
Provide patient-centered care
Values/ethics for interprofessional practice
Evidence of professional standing
Medical Knowledge
Work in interdisciplinary teams
Roles/responsibilities
Evidence of commitment to lifelong learning
Practice-based learning & improvement
Employ evidence-based practices
Interprofessional communication
Evidence of cognitive expertise based on performance
on an examination
Interpersonal & communication skills
Apply quality improvements
Teams and teamwork
Evidence of evaluation of performance in practice
Professionalism
Utilize informatics
System-based practice
CME office Section Comments:
Section F: Speakers or Author Selection & Topic Content Validation (PSNA forms and Disclosures)
Speakers & Authors: Please list all speakers or authors, their organizational affiliations, and the reason for their selection in light of the learning
objectives and the educational methods chosen. The term “speaker” applies to a presenter, moderator, facilitator, panelist, academic detailer, or
any other person developing content for the educational activity. Each speaker must complete a Disclosure Declaration & a PSNA form regarding
potential conflicts of interest and discussion of off-label or investigational use of products and validation of their content in which they are presenting.
(PSNA forms can be groups for speakers who are collaborating on a single topic; but still must each complete their own disclosure form. Moderators,
Facilitators, or panelists for Q/A do not need a PSNA form. For more specific questions, please contact [email protected] for assistance.)
Do I understand who a “speaker” is based on the definition above?
Yes No
Name
Affiliation
Reason for Selection
Draft Content Received
PSNA Form Completed
Disclosure Form Completed
insert more rows as needed
CME office Section Comments:
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Section G: Activity Communication & Marketing
How will you communicate the learning objectives and other relevant planning information to any speakers or faculty responsible for conducting or
Facilitating the educational activity?
Written communication
In-person discussion
Other:
How will you communicate the learning objectives and other important CME information to your target audience?
Written communication
Other:
Marking & Disclosures on Promotional Materials
What is the mechanism of making any disclosures and/or explanations? (Note: The CME office must approve disclosure statements/explanations for each
Mechanism selected. As required by ACCME, commercial support, the presence or absence of conflicts, and the discussion of off-label use of products must be disclosed
To participants in writing prior to the CME activity.)
Promotional flyer or brochure
Program handouts
Sign-in sheets
Other written mechanism:
Please forward all promotional materials (save-the-dates, brochures, flyer, etc.) to the CME office at least 2 weeks prior to the scheduled session for approval. Your marketing materials cannot
promote (or contain) any CME until it is reviewed and approved by us. Our office does provide a CME flyer template to assist you in this process, reach out to
cme@uchc.edu
for assistance.
Sign-in Sheet & Attendance: To receive CME credit, participants must record their live attendance to the activity. The usual method is the
Use of a CME sign-in sheet to track live attendance.
Please provide a brief description as to how you will be tracking your participants live attendance. How will you verify your participants attendance (examples include participant initials,
signatures, virtual-hosting platforms record of attendance, etc.)
To ensure you are collecting all the correct CME participant’s data point, please refer to the sample sign-in sheet below. You may copy this or adapt it for your use. You do not need to
Complete this for the application, only provide a final sample as an attachment.
First Name
Last Name
Degree(s)
# of Credits
email
address
city
state
zip
Initials to verify attendance
Sample only
Do not fill
CME office Section Comments:
Section H: Evaluations & Quizzes
Evaluation: In order to receive CME credit, participants are required to submit an evaluation for each CME activity attended.
Check the box next to the evaluation system you will use for the CME activity below and then attach and electronic copy of your evaluation form with this application.
Myevaluations.com (to be used for ONLY UConn/UCHC internal attendees – not for external/community participants; there are special parameters for the use of this system)
Paper or Electronic evaluations system (such as Survey Monkey or Qualtrics, etc.)
Other:
Please indicate how you will use the evaluation data (check all that apply).
Provide summary of feedback to speaker(s)
Provide summary of feedback to participants
Plan future CME activities
Other:
Quizzes: There are some CME activities that requires an activity quiz in addition to the evaluation. (Examples are Enduring Material CME activities
Or other Internet non-live activities etc.)
Does your educational activity require a quiz?
Yes No
Please briefly describe the nature of your educational activity and the nature of the quiz you will be developing.
Did you submit a copy of your quiz with answer to us?
Yes No
CME office Section Comments:
Section I: Educational Activity Budget
Income: list anticipated sources and amount of income/funding (or other funds) on each line.
Source (indicate $0 for any amount not applicable)
Amount
Department fund:
$
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Commercial Support:
$
Exhibit Income (From fees, etc.):
$
Advertisement Income:
$
Other Income: Registration Fees (registration, subscription, or publication fees received from activity participants) Provide attach spreadsheet with detailed breakdown.
$
Other Income: Government Grants:
$
Other Income: Private Donations (including grants from foundations)
$
Total “Anticipated” income/funding:
$
Your income/funding Comments (optional):
Expenses: list anticipated sources and amount of expenses on each line.
Source (indicate $0 for any amount not applicable)
Amount
CME Application Fee (amount supplied by CME office):
$
CME Commercial Support Surcharge (amount supplied by the CME office):
$
CME Enduring Material Surcharge (amount supplied by the CME office):
$
CME Joint Providership Surcharge (amount supplied by the CME office):
$
CME Certificate Fee (amount supplied by the CME office):
$
Honoraria: $ (per person) x (people)
$
Travel expenses:
$
Printing:
$
Mailing/Postage:
$
Room Rental for Event:
$
Food:
$
Hotel Accommodations:
$
Other expenses (please specify):
$
Other expenses (please specify): (insert more lines as needed)
$
Total “Anticipated” expenses:
$
Your expense Comment (optional):
Please provide below, the entity will absorb financial expense for this program?
Please provide below, what will happen with any profits from this event?
Account Information:
Please provide below, each account that will receive any funds for make any payments.
Account Information
Account 1
Account 2
Account 3
Name of Account:
Account Number (only for Uconn Health):
Person Responsible:
CME office Section Comments:
Section J: Application Checklist for Supplement Attachments to Submit (Needed for Full CME Application Review for Approval)
Use this checklist to help you keep organized and collect ALL the required attachments required for approval for your CME application. With many of these checklist items, we offer
Standard CME templates you can use to help you with this process. Please contact us at
[email protected]u
for more information.
ALL prelim activity disclosure forms collect & completed (including, activity director, co-activity director, activity admin, independent reviewer (if needed), planning committee members)
ALL speaker/author disclosure forms collected & completed
All PSNA forms for content validation collected & completed
All DRAFT speaker content slides/presentations for content validation collected & reviewed by activity director and planning committee
At least 2 sources of needs assessment data documentation collected for submission with application
Provide a sample of your sign-in sheet that you will be using for your CME activity (your sign-in sheet much include: first name, last name, degree(s), number of credits, email address,
Address, city, state, zip, and initials to verify attendance, we have a CME sign-in template if you wish to use this.)
Provide a copy of your evaluation form (single speaker or multi-speaker) if not using myevaluations.com
Provide a copy of your quiz and answers (if applicable)
Provide a copy of your CME flyer or brochure
Provide all your signed LOA agreements for commercial support (if applicable)
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Provide a map/diagram of where my vendors/exhibitors will be located (if applicable)
CME office Section Comments:
CME APPLICATION Final Signatures:
As the Activity Director, I attest to the accuracy and completeness of this application, and I accept the responsibility for the planning, implementation,
and evaluation of this CME educational activity. I agree to submit to a complete and accurate final report on this activity withing the deadline given.
X
X
Signature of Activity Director
Date
As the Department Chairperson, I attest that this CME activity has the sponsorship and support of the department.
X
X
Signature of Department Chairperson or Equivalent
Date
UConn School of Medicine
Office of Community & Continuing Medical Education
Email: [email protected]