CME Activity Closeout Form

CME Activity Closeout Form

INSTRUCTIONS: Use this form to close-out the CME documentation for your UTCOM-certified CME activity, and to request that we create & issue the CME credit certificates.

Activity Title:2017
Activity Dates:
Activity Location: / Activity Medical Director:
Activity Coordinator:

1. Total Hours of CME provided through this Activity:

Hours of CME
per Meeting or Course / X / Number of Times Offered
(some CME activities meet more than once) / = / Total Hours of CME
X / =

1. Participation - How many attendees will receive a Certificate of Participation for this activity?

What was the Total Participation for this activity?

For CME Courses and Enduring Materials this is simply the number of people that participated, but for Regularly-Scheduled Series or Journal Clubs with multiple meetings this is the sum of the attendance totals from all meetings. For example, if the seriesmet twelve times and had 20 attendees at each meeting, then the Total Attendance would be 12 x 20 = 240.

Of your Total Participation, how many were physicians? How many were non-physicians?

For CME Courses or Enduring Materials, simply count each physician and non-physician once (even if they participated multiple times). For Regularly-Scheduled Series or Journal Clubs, count each physician and non-physician each time they attended. For example, if the same 10 physicians attended each of the 12 meetings at your CME activity, you should enterthat 10 x 12 = 120are physicians (even though there are actually only 10 physicians).

Required Attachment #1: A Participation Report showing the first name, last name, degree, and number of hours of participation for each personreceivinga Certificate of Participation.The report needs to be an Excel spreadsheet. Click here or visit to download participation report templates. Rounding to the Nearest Quarter-Hour: Per the AMA’s rounding rule, CME time awarded should be rounded up or down to the nearest quarter hour. So participation of 1.35 hours would round down to 1.25 hours, and participation of 2.88 hours would round up to 3 hours. Certificates for Non-Physicians:We issue Certificates of Attendance to non-physicians for their participation in this CME activity, and they can obtain continuing education credits for participation in CME activities that award AMA Category 1 CreditsTM. If the Certificates will be Mailed: Your Participation Report needs to include the address, city, state, and zipcodefor each attendee. CME Activities with Multiple Meetings: If your CME activity had multiple meetings and you already closed-out the individual meetings, you do notneed to provide attendance reports again for those meetings. CME Credit for Speakers: Speakers may not receive CME credit through this activity for giving a presentation at this activity because the ACCME considers “this learning from teaching” to be a different learning activity from this CME activity, so your attendance report should not give your speaker(s) credit for giving their presentation(s); however, speakers can request CME credit directly from the AMA for their CME talks.

ATTESTATION: I attest that the Participation Report provided is accurate and commensurate to the best of my knowledge. Initials of Activity Medical Director or Activity Coordinator.

1. CME Content Validation & Consistency

ATTESTATION: I attest that all education provided at this CME activity was: a) the same speakers & topics approved by the Office of CME, b) within the scope of the Learning Objectives on the CME Credit Application for this activity, c) evidence-based, d) free from promotion, and e) not biased by commercial interests.

Initials of Activity Medical Director Initials of Activity Coordinator

1. Tennessee Board of Medical Examiners requirement for Education on Controlled Substances – As of 2014, the Tennessee Board of Medical Examiners(TBME) began requiring:

“All licensees shall complete a minimum of two (2) of the forty (40) required hours of continuingeducation in controlled substance prescribing, which must include instruction in the Department’s Chronic Pain Guidelines on opioids, benzodiazepines, barbituates, and carisoprodol and may includetopics such as medicine addiction, risk management tools and other topics approved by the Board.”

Did this activity provide education that meets this requirement?No, skip to section #5

Yes, please complete this table:

Title of the Session(s) that met this requirement: / Session Duration:

ATTESTATION:I attest that this session listed above meets the TBME requirement above.

Initials of Activity Medical Director or Activity Coordinator:

1. Commercial Independence forms– All planners, speakers, and everyone else in a position to control the planning, content, implementation, & evaluation of a CME activity must disclose all relevant financial relationships with a commercial interest to the UT College of Medicineby completing a Commercial Independence form(per page 7 of the CME Credit Application). (SCS: 2.1)

ATTESTATION:I attest that all individuals in a position to control the planning, content, implementation, & evaluation of this activity completed a Commercial Independence form prior to the activity.

Initials of Activity Medical Director or Activity Coordinator:

1. Disclosures to Learners – Per the CME Credit Application(page 9), several pieces of information must be disclosed to the learners at a CME activity(SCS: 6.1, 6.2, ): 1) the learning objectives, 2) the AMA Credit statement and Accreditation statement, 3)the relevant financial relationships (or lack thereof) for all speakers and4)any commercial support received for this activity (if applicable).

ATTESTATION:I attest that this information was disclosed to the learners at this activity.

Initials of Activity Medical Director or Activity Coordinator:

1. Summary of the Evaluations– Evaluations are used to ensure that the audience did not perceive commercial bias in the presentation(s) and as a source of feedback for the activity. You must summarize the responses received on the evaluations for this CME activity(AC-13).

Required Attachment #2: A summary of the responses received on your evaluations. Evaluation summaries can be as simple as a few sentences summarizing the feedback, more quantified such as indicating the number of people that responded a certain way for each question,or can include more elaborate statistical analysis such as generating averages (expressed as a percentage %) for the responses for questions, but at a minimum the Summary of Evaluations needs to include (a) how many evaluations were received and (b) either a few sentences summarizing the feedback received OR the number of people who responded each way for each question. CME Activities with Multiple Sessions: If your CME activity had multiple sessions or meetings and you already closed-out the individual sessions, you have already satisfied this documentation requirement and do notneed to provide anything for this attachment.

1. Commercial Support – Commercial support is monetary or in-kind contributions received from a commercial interest used to all or part of the costs of a CME activity. (A commercial interest is an entity that produces, markets, re-sells, or distributes health care goods/services consumed by or used on patients.)

Exceptions by Organization Type: Hospitals and other providers of clinical service directly to patients are not considered commercial interests.

Exceptions by Income Type: Commercial exhibits and advertisements are promotional activities and not continuing medical education, so monies paid by commercial interests for these promotional activities are not considered commercial support(ACCME).

Was commercial support received for this activity?No, skip to the next page

Yes, fill out the information below:

Commercial Interest that provided support:(organization name) / Amount (or Type) of support received: / What part of this activity was the commercial support used to support?

ATTESTATION:I attest that all commercial support received for this conference is disclosed above.

Initials of Activity Medical Director or Activity Coordinator:

Attachment #3, A Letter of Agreement isRequired if commercial support was received: You must provide a letter of agreement for each disbursement of commercial support that was (or will be) received for this CME activity. See page 11 of the CME Credit Application (visit to download it) for more information about letters of agreement for commercial support.
Attachment #3b, Required if the expenditure (use) of commercial support is not detailed in the letter of agreement: You must provide documentation that details the expenditure/use of commercial support (i.e., what was the money used for?) if it is not clearly indicated on the letter of agreement(SCS: 3.13).
CLOSEOUTDOCUMENTATION CHECKLIST

The following documents *must be provided with closeout. Check the boxes to indicate attachments you have already assembled so that you know which ones you still need as you prepare your closeout documentation.

Attachment #1: A Participation Report for this activity. (seesection 3, page 1)

Attachment #2: A Summary of the Evaluations for this activity. (see section 6, page 2)

*Exception for CME Activities with Multiple Meetings: If this CME activity had multiple meetings and you already closed-out the individual meetings, then you do not need to provide the supporting attachments above.

Additional Attachments: Required if Commercial Support was Received

Attachment #3: A Letter of Agreement for each disbursement of Commercial Support(see section 7, page 3)

Attachment #3b: Documentation that details the expenditure of all Commercial Support received(see section 8, page 3)

/ Visit templates and other resources for the required documentation.
CERTIFICATES OF ATTENDANCE FORMAT

How would you like us to issue the Certificates of Attendance for this CME activity?

Mail – the certificate will be mailed to each attendee.

Email – a PDF of all certificates will be emailed to the Activity Coordinator.

CME Coordinator: Check to see if this activity met the TN Medical Board Examiner’s Controlled Substances Requirement (page 2)

ATTESTATION & SIGNATURES

I attest that all information provided through this closeout form and the supporting documents is accurate and complete to the best of my knowledge.

Signature of Activity Medical Director (typed or signed) / Date
Signature of Activity Coordinator (typed or signed) / Date
/ Have feedback about the CME process? We are always seeking to improve our process and services. Let us know by sending an email to
OFFICE USE ONLY
CME Closeout Approval – Reviewer: Date Reviewed://
Certificates – Created by: Delivery Method: Email Mail Date Issued://
Issued via: In Mass, sent to: Individually, sent to each Physician

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