Continuing Medical Education

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Application for Continuing Medical Education “Learning from Teaching” Activity

Activity Title: ______

Presentation Title: ______

Presentation Date: ______Location: ______

Amount of teaching time?1 hour2 hoursother______

Presenter: ______Academic Title: ______

Email Address: ______Phone: ______Fax: ______

Mailing Address: ______

Describe specific problems or challenges for you, learners and/or patients that will be addressed through this presentation?

Professional/Practice Gaps (Identify minimum of 1) / Gap in
1. / Knowledge
Competence
Patient health
2. / Knowledge
Competence
Patient health

What resources (data) were used to identify these gaps? (Check all that apply and include a minimum of 2 data sources with your application).

Data Sources
Inferred Needs / Expressed Needs / Data Driven Needs
New diagnostic and treatment methods
The availability of new medications or new indications
New technology or new applications for existing technology
Expert opinion about advances in medical knowledge
Acquisition of new equipment or facilities
Legislative, regulatory, organizational changes affecting patient care / Requests from participants in your current series
Results of formal surveys
Informal comments among colleagues
Consensus of physicians in a department / Epidemiological data
Evidence Base Guidelines
QI/QA data
Morbidity/Mortality data
Hospital statistical data e.g. infection control
Information from recredentialing reviews
Procedural Statistics e.g. surgical
External requirements e.g. professional society guidelines, licensure
Evidence based journal articles

Learning Objectives: Describe what you want to know or do differently as a resultof this learning from teaching activity?

1.

2.

3.

Activity Planners: List all persons that were in a position to control or influence the content of this learning from teaching activity.

Name (please print) / Title / Organization
Self

Describe the educational plan you will initiate or participate in to change your own knowledge, competence, and/or performance.

______

______

______

______

______

Whatprofessional/practice gaps do you expect to improve as a result of thislearning from teaching activity?

Competence Performance Patient health outcomes. (Check all that apply and please explain below)

______
______

______

Evaluation/Outcomes Assessment: How will you measure the effectiveness of this teaching from learning activity?

Ratings on participant surveys of good or better

Indication on participant surveys of commitment to change practice

Improved patient health

Other (please explain) ______

Commercial support: Did/willyou receive commercial support for this presentation? YesNo

Submitted by: ______Date: ______

Email address: ______Phone: ______