Please Return Completed Form By

61stSNMMI Annual Meeting

June 7-11, 2014

St. Louis, MO

Organizational Form

PLEASE RETURN COMPLETED FORM BY:

December 10, 2013

To:

SNMMI

Stephanie Torres, Program Manager - Education

Phone: (703) 652-6782

Fax: (703) 667-5132

Email: – preferred

Title of Session:

Organizer(s):

Moderator:

Co-Moderator:

Instructions for Session Information

Please provide the CME/CE Content Category.

Content Category-Systems (Check all that apply):

___Basic Sciences

___Cardiovascular

___Endocrinology

___Gastrointestinal

___Genitourinary

___General Nuclear Medicine

___Molecular Imaging

___Musculoskeletal

___MRI

___Neurology

___Oncology

___Pediatrics

___Professionalism

___Patient Safety/Radiation Safety

Content Categories – Modalities

___CT

___Cardiovascular

___MRI

___PET

___Therapy

___Practice Performance Assessment

___SPECT

___PET/CT

___SPECT/CT

This session will be designed to change:

Competence (changes in how to apply knowledge to practice)

Performance (changes in practice performance as a result of the application learned)

Patient Outcomes (changes in health status of patients due to change in practice behavior)

Based on the Maintenance of Certification (MOC) competenciesdesignated by the American Board of Medical Specialties (ABMS) and ACGME, please indicate which competency area(s) this session addresses:

Patient care (Provide care that is compassionate, appropriate and effective treatment for health problems and to promote health)
Medical knowledge (Demonstrate knowledge about established and evolving biomedical, clinical and cognate sciences and their application in patient care)

Practice-based learning and improvement(Able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence and improve their practice of medicine)

Interpersonal and communication skills(Demonstrate skills that result in effective information exchange and teaming with patients, their families and professional associates (e.g. fostering a therapeutic relationship that is ethically sounds, uses effective listening skills with non‐verbal and verbal communication; working as both a team member and at times as a leader)

Professionalism (Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations)

System-based practice(Demonstrate an awareness of and responsibility to a larger context and system of healthcare. Be able to call on system resources to provide optimal care [e.g. coordination of care across sites or serving as the primary case manager when care involves multiple specialties, professions or sites])

Complete Summary of Course

Purpose of the course
An indication of its relative emphasis on “basic” or “clinical” knowledge
Intended audience
An explanation of how the course relates to attendees’ needs
Expected outcomes (in terms of changes in performance, competence or patient outcomes)

Course Education Learning Objectives (at least one objective must be written at a higher level for the course): The take-home messages; what should the learner be able to accomplish after the activity?

Examples of higher level learning objectives:

Examine important incidental findings on PET and CT and understand how to avoid potential pitfalls.
Interpret FDG PET studies performed for suspected tumors.
Manage and mitigate CT Radiation exposures in the clinical environment.
Compare available instrumentation for PET and PET/CT including selection of detector systems and theory of operation.

Upon completion of this session, the attendees will be able to:

1. ______

2. ______

3. ______

LEARNER OUTCOMES/ Desired Results - Please list what learners can expect to do in his/her practice (Learner outcomes are listed in the order of talks – one item per talk).

______
______
______

Instructions for Presentation & Faculty Information:

*Please provide the titles of presentations and names of Faculty beginning in chronological order.

*Please be as accurate as possible.

*Please note:employees of commercial companies cannot present content that is related to the interests, products, or services of their employer. Any speaker who is an employee of a commercial company must be recused or eliminated from any activity if discussions or questions move to areas related to their employer.

*Panel discussions and questions and answers should not be written as presentation titles.

What criteria will be or were used in the selection of the faculty?

Subject matter expert

Experienced in continuing medical education

Willingness to disclose financial relationships

Willingness to address activity objectives for the learners

Excellent teaching skills

Effective communicator

Minimal or no relevant financial relationship with commercial interests

Other (please describe):______

Would you like this course designed as a Self-Assessment Module (SAM) ______Yes______No

Please indicate the educational methods (or design) proposed for this session based on the target audience, and desired results.

Check at least two methods and all others that apply.

Didactic lecture with scheduled Q&A / Case Presentations/discussion
Panel Discussion / Question & Answer
Audience Response System (ARS) / Debate
Small group discussion / Diagnostic Images
Games
Other (please describe):______
______

1.Presentation Information:

Title:

Start Time:End Time:

Name:

Company/Institution:

Phone:

Email:

SNMMI Member?

7.Presentation Information:

Title:

Start Time:End Time:

Speaker Information: (All lines MUST contain complete information)

Name:

Company/Institution:

Phone:

Email:

SNMMI Member?

8. Presentation Information:

Title:

Start Time:End Time:

Speaker Information: (All lines MUST contain complete information)

Name:

Company/Institution:

Phone:

Email:

SNMMI Member?

9.Presentation Information:

Title:

Start Time:End Time:

Speaker Information: (All lines MUST contain complete information)

Name:

Company/Institution:

Phone:

Email:

SNMMI Member?