CME ACTIVITY PLANNING FORM (Updated 2009)

Please note that this CME Activity Planning Form is provided on the web as a reference for faculty, planners, and/or non-accredited institutions interested in offering continuing medical education opportunities with the Central Illinois Neuroscience Foundation (CINF). All activities must be approved by CINF’s Continuing Medical Education Unit prior to being delivered to learners. Non-accredited parties interested in joint sponsorship opportunities should contact the CINF for the most updated application procedures and materials.

Date of Application
Program Title:
Program Location:
Address:
Is the facility ADA (American’s with Disabilities Act) compliant?
Program Type:
Date(s) of Program:
Time of Program:	Start Time:	End Time:
Category 1 Credits Requested:	Total Credits Requested:	Total Number of Activities:
Total Credits Requested:
Joint Sponsor Organization (if applicable):
Course Director:
Address:
City:	State:	Zip Code:
Phone:	Fax:
E-mail:
Person with administrative responsibility for the educational program
If other:	Name:
Address:
City:	State:	Zip Code:
Phone:	Fax:
E-mail:

ESSENTIAL AREA I – Purpose & Mission
How does this activity “fit” with the Central Illinois Neuroscience Foundation’s Continuing Medical Education Mission Statement?
ESSENTIAL AREA II – Educational Planning & Evaluation
Planning Committee Please list all members of the Planning Committee for this program. Please attach Planning Committee Disclosure Forms for each member listed (required). If a conflict of interest is identified, please indicate how the conflict was resolved in the section below.
Name	Degree	Title	Phone	Disclosure	COI?
Conflict of Interest Resolution
Planning Process Briefly describe the planning process for this program/series. Include a record of your planning timetable, e.g., meeting minutes, etc., which identify needs, development of objectives, educational strategies and selection of faculty.
Needs Assessment/Gap Analysis How was the need or interest for this program/series identified by your organization? Please check all that apply (minimum of two required) and attach samples of each.
Evaluation of a previous CME activity identified a need for further information A formal request from a Committee/Council/Board/Department. Please specify: A new program/technique/medical issue has been identified: A need was identified through a survey of the prospective audience (interviews, questionnaires, etc.) Quality Assurance/Utilization Review/Morbidity and Mortality data indicated a need for this program/series Chart audit Recommendations or statements from leading organizations or experts: Focus Group Community concerns Published Articles/Research. Please specify topic and conclusion (include supporting documentation): Public health data Other, please specify:
What is/are the issue/problem to be addressed by this activity? What specifically was learned from the needs assessment data, e.g., percentage of physicians not following national guidelines, etc. (C3) Is/are there quality gap(s) that this CME activity is trying to address? (C2)
Given the identified need, what this the practice gap this activity will address? The practice gap – the difference between where the learners are and where they should be – must be described as a change in competence, practice/performance or patient outcomes. (C2)
Are there potential or real barriers facing the learners that would prevent them from applying the knowledge to change performance or improve patient outcomes?
Are there strategies that can be implemented to remove, overcome or address these barriers?
Are there other factors, outside of your control, that may impact patient outcomes related to this activity?
Cultural Competency Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. “Culture” refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious or social groups. “Competence” implies having the capacity to function effectively as an individual and an organization within the context of cultural beliefs, behaviors, and needs presented by consumers and their communities (adapted from Cross, 1989).
Has the cultural competency of the target audience been assessed?
Has a gap been identified in the cultural competency of the target audience?
If a gap in cultural competency was identified, how will it be addressed in this activity?
Target Audience CME activities are intended to increase knowledge, enhance competency, and/or influence behavior with the goal of improving patient outcomes. The purpose of an activity should focus on closing the gap(s) identified in your target audience based on needs assessment. Please specify the physician target audience for who your program is intended. Secondary audiences for who this program may also benefit, such as nurses, technicians or other allied health professionals, should also be listed.
Physician Audience (specify specialities):
Health Professionals (please specify):
Students/Residents (please specify):
Other (please specify):
Estimated Attendance:	Physicians:	Non-Physicians:
Learning Objectives The gap(s) identified in your needs assessment should always be considered before the learning objectives and educational content are determined. Learning objectives can be thought of as “stepping stones” that help learners understand the nature of the identified gap(s). Well thought out learning objectives also serve as a guide for instructors so that they create content that will help learners close the identified gap(s). Based on the learning needs identified in the Needs Assessment section, please list the learning objectives for this program below. Note, behaviorally-oriented learning objectives should possess the following characteristics: directly relate to the identified needs focus on one or more areas – knowledge transmission, skills development, attitudinal change, changes in physician practice application, or changes in patient health status be written so that attainment can be measured an evaluated For each learning objective, identify the program content/teaching/learning activity which addresses each objective. Please submit additional learning objectives on a separate sheet if more space is required.
At the conclusion of this learning activity the participant should be able to:
Learning Objective List individual learning objectives. Please note that these objectives must be the same as those listed in the advanced promotional materials and final program.	Content Identify corresponding content	Core Competency* Which of the core competencies best describes the nature of the objective?
Example: Summarize the latest trends in the management of epilepsy	New Advances in Epilepsy: John Smith, MD
* Core Competency : Refers to a specific categorization system of physician competencies that are central to the practice of medicine Patient Care: compassionate, appropriate and effective for the treatment of health problems and the promotion of health (e.g., physical exam; decision-making; problem-solving) Medical Knowledge: about established and evolving biomedical, clinical and cognate (epidemiological and social –behavioral) sciences and the application of this knowledge to patient care (e.g., up-to-date aspects of illness – symptoms, management) Practice-Based Learning & Improvement: involves investigation and evaluation of patient care, appraisal and assimilation of scientific evidence, and improvements in patient care (e.g., performance improvement) Interpersonal & Communication Skills: results in effective information exchange and teaming with patients, their families and other healthcare professionals (e.g., communication with patients/colleagues) Professionalism: manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population (e.g., integrity, initiative, mutual respect, punctuality, accountability) Systems-Based Practice: manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of healthcare and the ability to effectively call on system resources to provide care of optimal value (e.g., patient safety, cost-effective care, integrative improvement)
Learning Methods The educational methodology and format should reflect the gap(s) identified in your needs assessment. Whenever possible, adult learning principles should be taken into account when selecting appropriate educational methodology.
Lecture: Formal prepared presentation by one or more individuals. Lecture/Discussion: Lecture followed by active discussion by those present. Case Presentation/Discussion: Short presentation of one or more cases followed by extended discussion with participants. Workshop/Skills Lab: Small sessions with interactive groups of 8-12 with specific activities to be accomplished. May include short case presentations or performance of manipulative skills under supervision. Panel Discussion: Two or more experts addressing individual issues with questions from the floor or short topics presented by a moderator. Performance Improvement: Physician identified educational need through a measure of his/her performance in practice, followed by self-prescribed learning experiences to meet the need, integrating learning into patient care, and reevaluation of performance. (3 distinct parts; completion of all = 20 AMA PRA Category 1 credits™. Procedure Demonstration: Includes evidence-based discussion and review of indications/contraindications. May include use of film, videotape, closed circuit television or other mechanical aids. Simulations: Paper and pencil or live encounters with clinical problems specifically designed for educational purposes. Other, please specify:
Evaluation Methods Evaluation is a process that attempts to systematically and objectively determine the relevance, effectiveness and impact of activities in light of their objectives. Evaluations can be related to structure, process or outcome and should relate to the desired results of the activity. Program evaluation methods that emphasize changes in physician performance or behavior, or patient outcomes are suggested. Check all of the boxes for techniques you plan to use to evaluate the effectiveness of this program/series in terms of individual physician learning achievement. A sample evaluation form must be attached to this application.
Method of Evaluation Competence Performance Patient Outcomes Post-Program Satisfaction Survey Faculty Questionnaire Pre/Post Testing Self-Reporting (key points) Case Studies Demonstration 3-6 Month Follow-Up Audience Response System Focus Groups Chart Audit
Written test/quiz Follow-up written or online survey Follow-up medical audit/chart review Follow-up quality assurance / utilization review / morbidity and mortality data Change in referral patterns Performance/competency test Skill appraisal by trained supervisor Faculty/Observer critique Other, please specify:
Note: An evaluation summary MUST be sent to the Central Illinois Neuroscience Foundation following the completion of the activity. This report must include a summary of responses, attendance, and how this information will be used or incorporated into future programs. Based on the techniques indicated above, the CINF may request additional information and follow-up.
Faculty Selection & Documentation Speakers should be chosen based on their knowledge, skill and expertise. Please list the speakers for your program below including contact information, and note any conflicts of interest identified on the disclosure form. Note that ALL conflicts of interest MUST be resolved prior to the activity being delivered to learners. Documentation of conflict resolution MUST accompany the application. Make additional copies of this form as needed. In addition, CINF requires a copy of each speaker’s curriculum vitae and a copy of the correspondence between the non-accredited provider and the speaker that documents the communication of learning objectives, evidence-based clinical content, conflict of interest/disclosure, HIPAA compliance, and instructions to disclose to the audience when discussing an off-label or unapproved use of a commercial product.
1.	Name:	Degree:
Title:
Address:
City:	State:	Zip:
CV Attached?	Disclosure Attached?	Conflict of Interest Identified?
If a conflict of interest was identified in the disclosure process, please note the commercial interest, the nature of the relationship, and the steps taken to resolve the conflict.
2.	Name:	Degree:
Title:
Address:
City:	State:	Zip:
CV Attached?	Disclosure Attached?	Conflict of Interest Identified?
If a conflict of interest was identified in the disclosure process, please note the commercial interest, the nature of the relationship, and the steps taken to resolve the conflict.
3.	Name:	Degree:
Title:
Address:
City:	State:	Zip:
CV Attached?	Disclosure Attached?	Conflict of Interest Identified?
If a conflict of interest was identified in the disclosure process, please note the commercial interest, the nature of the relationship, and the steps taken to resolve the conflict.

ESSENTIAL AREA III: Administration
Budget As an accredited provider of continuing medical education, it is the responsibility of CINF to ensure that activities are planned and implemented with sound business and management polices and procedures (as it relates to human resources, financial affairs and legal obligations) so its obligations and commitments, and those of its joint sponsors, are met.
INCOME	EXPENSES
Tuition/Registration	$	X	$	Honoraria (if multiple speakers, please itemize)	$
Commercial/Industry Support	$	Travel/Lodging/Expenses	$
Other Support	$	Facility Charge (Room setup/AV equipment)	$
If there is a deficit, how will it be covered?	Promotion (mailing, advertising, printing, postage)	$
Administrative Overhead (supplies, human resources)	$
TOTAL INCOME	$	TOTAL EXPENSES	$

Commercial Support This activity must comply with the ACCME (Accreditation Council for Continuing Medical Education) Standards of Commercial Support. Please note that in a joint sponsorship relationship, outside sources (i.e., pharmaceutical companies or other commercial entities) may not directly pay a speaker or facility any funds for expenses, travel or honorarium. All monies from commercial supporters shall be paid to the Central Illinois Neuroscience Foundation in the form of an educational grant and disbursed according to the approved budget and a fully executed Letter of Agreement must be on file. Please refer to the Agreement for Joint Sponsorship for further information.
Contact	Company	Phone Number	Amount of Grant	Letter of Agreement

Marketing/Promotion A draft copy of all marketing and promotional materials (brochures, flyers, etc.) must accompany this application.
How do you intend to market this activity to the desired target audience? Mailing of brochures / flyers Blast E-mails Newsletter Blast faxes Live Events Website Other: ______________

IDENTIFYING EDUCATIONAL PARTNERS
Do you have educational partners for this activity? Yes No
If yes, please identify:
If yes, in what ways have you incorporated these other internal or external groups in the planning of this CME activity to help close the identified gap?
Are non-educational strategies (e.g., patient reminders) currently being used, or planned to be used, to help close the identified gap or enhance learning? Yes No
If yes, what strategies are being used?

Checklist of Required Attachments

Agenda/Syllabus/Outline
Conflict of Interest/Disclosure Forms
Planning Committee Members
Faculty Members
Planning Process Documentation
Needs Assessment Sources
Evaluation Form
Faculty Curriculum Vitae
Faculty Correspondence
Letters of Agreement
Preliminary Budget
Marketing Materials (drafts)
CINF Joint Sponsorship Agreement (if applicable)

Joint Sponsorship Checklist of Material to be Submitted by the Non-Accredited Sponsor to CINF for its Records (prior to or following the event – materials do not have to accompany this application)

Final copy of all course materials (slides, hand-outs, workbooks)
Registration/sign-in roster (original)
Documentation of disclosure being provided to the audience
Evaluation form and attendance summary
Electronic database of participants
Final marketing materials (flyers, brochures, etc.)
Final budget summary

A copy of the proposed agenda/syllabus/outline must accompany this application

If a Planning Committee member reports a conflict of interest on the disclosure statement, an attachment documenting how the conflict was resolved MUST be included with this application.

Must comply with the Standards for Commercial Support

Please provide a detailed listing of other sources of funding