SAINT LOUIS UNIVERSITY CME
Application for Approval of AMA PRA Category 1 Credits™
For Live Regularly Scheduled Conferences
MUST BE TYPED no hand written applications will be accepted. Yellow highlights are required areas to be completed.
Request Date:
Sponsoring Department/Organization:
Activity Title: ______
Event Date:
Type of Activity: □ Regularly Scheduled Conference (RSC)
□ Weekly DAY______TIME______Location______
□ Bi-Weekly: DAY______TIME______Location______
□ Monthly DAY______TIME______Location______
□ Other ______
DAY______TIME______Location______
AMA Credits* Requested:
60 minutes of education = 1.0 credit. (Credits may be estimated.) SLU CME staff will check the activity content and determine the number of approved AMA credits that will be awarded for this activity.
Per the AMA’s Core Requirements, to be certified for AMA PRA Category 1 Credit™, each activity must:
· Conform to the AMA's definition of CME.
· Address demonstrated educational needs.
· Communicate to prospective participants a clearly identified educational purpose and/or objectives in advance of participation in the activity.
· Be designed using AMA approved learning formats and learning methodologies appropriate to the activity's educational purpose and/or objectives; credit must be based on AMA guidelines for the type of learning format used.
· Present content appropriate in depth and scope for the intended physician audience.
· Be planned in accordance with the relevant CEJA opinions and the ACCME Standards for Commercial SupportSM, and be non-promotional in nature. (ALL PLANNING MEMBERS DISCLOSURE INFORMATION MUST BE COLLECTED DURING THE FIRST STAGE OF PLANNING. ALL PLANNERS’ FORMS MUST BE SUBMITTED ALONG WITH THIS APPLICATION.) Please review page two of the disclosure form for more information regarding who qualifies as a planning member for this activity.
· Evaluate the effectiveness in achieving its educational purpose and/or objectives.
· Document credits claimed by physicians for a minimum of six years.
· Be certified for AMA PRA Category 1 Credit™ in advance of the activity; i.e. an activity may not be retroactively approved for credit.
· Include the AMA Credit Designation Statement in any activity materials that reference CME credit with the exception of "save the date" or similar notices.
Target Audience: (Who will you promote your activity too? Who should be in attendance due to the educational strategies you are teaching?)
______
Course Director: Phone: ______
E-Mail:______Fax #:
Other Administrative Contact: Phone: ______
E-Mail: Fax #:
Budget:
Attach your program budget. List all sources and amounts of income anticipated and itemize general expenses including faculty travel and honoraria. Post-activity financial reconciliation is required (document template will be provided once application is approved). Expenses will need to be backed up with invoices or receipts.
Funding: Sources of funds: *Internal Funds Commercial Contributions*
Other (Grant,etc.): ______
*A Commercial Letter of Agreement (LOA) is required in advance for all industry supporters. Please refer to the Policy for Commercially Supported Activities to insure compliance with guidelines. We are unable to use contributions without the Letter of Agreement (LOA) approved and signed by all parties prior to the activity. Contributors must not be listed as supporters or attend the meeting without the fully executed LOA.
This form can be found on the SLU CME website. Only three persons in the School of Medicine have signature authority to sign LOA’s and ESA’s. As noted on the forms signature authority is according to the dollar amount of the grant. When downloading the forms please make sure to choose the correct one. All LOA’s must be routed to the SLU CME office for review and routing to the correct approver.
All expenses relating to the CME activity must be tracked with invoices, receipts, and or justification. Commercial Support companies can audit the use of funds for up to four years after the close of the activity. The CME office will require complete close out and documentation for the CME activity file from joint sponsors and SLU departments. If the SLU CME office fully manages the activity we will track expenses and complete the close out of financial information otherwise it will be your responsibility. Failure to provide the required information will put the activity into non-compliance and will determine future activities approval.
Post financial form will be sent as a tool for reporting and collection of expense documentation.
AMA PRA Credit Levels
Please check the level you are planning your activity for:
□ Verification of attendance: The physician attended and completed the course.
□ Verification of satisfactory completion of course objectives: The physician satisfactorily met all specified learning objectives.
□ Verification of proctor readiness: The physician is "proctor ready," which subsumes levels 1 and 2 and asserts the physician can successfully perform the procedure under proctor supervision.
□ Verification of physician competence to perform the procedure: Competence asserts the physician can successfully perform the procedure without further supervision.
Estimated Attendance:
SLU Physicians: Other Physicians: Residents/Fellows: Others:
Total expected attendance:
Evaluation and Outcomes Measure:
Ask yourself or your planning team the following questions. If you cannot come up with the answer then you need to rethink why you are providing the education and what the achieved outcome will be.
“What will you (the learner) change after attending this educational activity to improve patient outcomes?”
“Have you learned a new tool or competency (strategy) by attending this educational activity?”
The above questions are samples to help you tie the identified gap to the desired outcome. Your team will need to determine what question to include on the evaluation or follow up questionnaire in order to achieve your desired outcomes measure.
Check the level you want to achieve through your educational intervention:
□ Level 1: Reaction: Extent of participation and acceptance by the Learner
□ Level 2: Learning: Acquisition of new skills and knowledge by the Learner
□ Level 3: Behavior: Changes in Learner’s clinical practice
□ Level 4: Results: Changes in patient health outcomes
□ Level 5: Changes: Changes in population health outcomes
Planning Notes:
Please keep copies of notes pertaining to content, faculty selection, and format of educational activity to demonstrate all planning was done independent of all commercial interests.
______
Remaining sections must be completed and submitted to the CME office along with supporting documentation to prove your identified educational gap(s)..
Specify the educational or professional practice gap(s) that underlies the objective(s) that the activity will address. The “gap” is defined as the difference between the current state of knowledge, skills, competence, practice, or patient outcomes and the ideal or desirable state.
Provide proof of how you identified the gap (attach surveys, hospital data, new product sheets etc)
List the titles of the attached data and state how they prove there is need for this education.
Desired/ideal state of knowledge, competence, performance, clinical/patient outcomes
List what you want the participants to achieve as a result of the education you provide; include desired measurable data outcomes, if available.
COURSE OBJECTIVES: (so the learner will know what they are going to learn and if it fits into their scope of practice) What will the participant learn (take back to practice) from the tools or strategies that I teach during my presentation?
How to write an approved objective:
Examples of approved structure of learning objectives:
At the conclusion of this activity, participants will be better able to:
· Integrate clinical imaging into their practices for diagnosis of neuropathic strabismus
· Manage patients with craniostenosis from birth to adulthood, and predict and treat the potential ocular adverse sequelae
· Assesswhich patients are better suited for each type of cataract surgery
· Identify ptosis and eyelid abnormalities in adults and perform new blepharoplasty surgical techniques to correct ptosis
When writing your objectives please avoid the following terms (they are not measurable outcomes):
• Appreciate• Comprehend
• Internalize
• Recognize / • Be acquainted with
• Enjoy
• Know
• Remember / • Be aware of
• Grasp the
significance of
• Learn
• Sympathize with / • Be familiar with
• Increase interest
• Perceive
• Understand
Suggested/ Approved Terms
• Adjust
• Articulate
• Classify
• Convey
• Diagnose
• Distinguish
• Hypothesize
• Infer
• Organize
• Prioritize
• Relate / • Apply
• Assess
• Compare
• Create
• Diagram
• Employ
• Identify
• Integrate
• Plan
• Produce
• Select / • Appraise
• Categorize
• Conduct
• Demonstrate
• Differentiate
• Evaluate
• Illustrate
• Interpret
• Predict
• Recognize
• Solve / • Arrange
• Choose
• Construct
• Develop
• Discriminate
• Fomulate
• Implement
• Manage
• Prepare
• Recommend
• Use
COURSE OBJECTIVES
Write objectives that relate to the gap information you provided above:
Considering socio-economic, racial, religious, and cultural disparities, will your educational activity be planned to improve equity in healthcare? (GOAL: All people treated with the highest quality of care. ) ___ yes ___ no
If yes, please explain how your educational activity will identify and address issues to diversify and eliminate disparities?
Check List: (make sure all items are completed and attached or the application will be sent back for corrections)
______AMA application reviewed and discussed with planning team
______Scope of work accepted by planning team for implementation of requirements
______AMA application signed and dated by course director
Required attachments
_____ proof of needs assessment (surveys, articles, evaluations, expert opinion, etc…)
_____ budget estimates for expenses and income
_____ all planners’ conflict of interest/disclosure forms (confirm that all questions have been answered)
When above check list is complete the course director(s) should sign and date. If questions regarding the application are unresolved please contact the CME office for further discussion.
or Phone: (314) 977-7401
Please make sure the application is signed by the course director prior to sending the document to the CME office
COURSE DIRECTOR’S SIGNATURE (REQUIRED):
Signed: Date:
Print Name:
Email complete packet to: or mail to the CME Office (faxed applications will not be reviewed)
SAINT LOUIS UNIVERSITY SCHOOL OF MEDICINE
Young Hall
SLU CME Office
3839 LINDELL BLVD., ST. LOUIS, MO 63108
DO NOT WRITE BELOW THIS LINE
DATE RECEIVED:
Initial Review by: Date:
□ Recommend for Approval □Approval with Changes □Disapproved/Incomplete
COMMENTS:
REVIEWED AND APPROVED DATE
For additional information, contact CME at: or Phone: (314) 977-7401
Activity Title ______
Date of Activity______
Date entered into PARS report ______
Date entered into CME database ______
Activity code as assigned in database ______
Please reference activity code on all course materials. This code will be used for designation of continuing education audits.
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RSC Application CME/CE approval Revised form 12/2012