Proposed CME Activity- (Name of Event)

Please provide the information below and complete the attached budget sheet. Submit this form and budget sheet by e-mail to the CME Program to: r by fax to 806-723-7023.Please present requests at least two monthsprior to the event.

This information will be presented to the CME Committee for approval (see #23). Letter of decision onFinal Approval will be sent to the requestor and CME Activity Director for this CME along with the date of the event.

1.Name of Requestor:

2.Date of Request Submitted:

3.Title of Proposed Activity:

4.Speakers or Presenters:

5.Proposed Date(see CME event calendar for open dates)

(First Choice):(Second Choice):

6.ProposedTime for Activity(8am-12pm):______

7.Proposed Location(If at Covenant, please contact Terri Krueger at 806-725-0476 or check availability at

8.Type of Activity

___ Live___ Videoed & Posted Online___ Online Webinar

___ Lectures Only___Lecture/Workshop#of Workshops

___ Regularly Scheduled (Grand rounds, etc)___ Enduring Material ___ Other

9.Number of AMA PRACategory I Credits Requesting(Up to 7 credits rounding to the nearest quarter hour, 60 minutes = 1 hour of AMA PRA Category 1 Credits )?

10.Please indicate what other type of credit you are requesting?

____CNE (Please note a nurse planner must be on the planning committee if it is for CNE)

____Social Worker

____Other- Please indicate what:______

11.Who willserve as the activity director (activity director is a physician) to ensure content is appropriate and speakers are experts in the topic they are addressing?

Activity Director is responsible for verifying all speakers and planners disclose all relevant financial interests, identify the educational need/gap and develop the educational program and the activity’s content, Verifying the content is free of commercial bias, Insuring that continuing medical education activities comply with Covenant’s CME Policies and Procedures.

12.Please indicate name(s) of all Planners for this activity(anyone who will be involved in this event, All Planners must complete a Disclosure Form prior to the CME Activity):

13.Covenant Sponsoring Department:

Phone:Email:

Office Address (Box # if at Covenant):

14.(C3)Explain WHY this Activity is needed (What data can you cite that supports this?

(Please Attach supporting data & cite evidence of your Need for CME):

15.WHO are you trying to help? (this is the target audience; which specific staff orphysicians will you address)

16.Is this activity for Ethics credit? ____ YES _____ NO

Ethics Requirement for CME per Texas Medical Board:

Ethics/Professional Responsibility courses are considered to be those that address the principles of proper professional conduct concerning the rights and duties of the physician, patients, and fellow practitioners, as well as the physician’s actions/relations concerning patients and their families.

17.Is the Target Audience Local orRegional?

If regional, please provide specific target cities and radius to be included:

18.(C3) How does this activity fit within our mission for CME?

See CME Mission at

(See areas: Purpose, Content, Target Audience, Types of Activities, Expected Results)

19.Which Covenant/St JosephGoal(s) does this Proposed CME Activity align with?(You can find the goals at S:\Public\Strategic Development\FY2011-2013 Strategic Plan)

20.Will another hospital be involved in planning this activity? ___ YES___ NO

Name of this hospital:

21.Is the completed budget sheet attached?___ YES___ NO

If no, please complete prior to submission, for questions please contact the CME Office.

22.Are you interested in applying for grants for this activity? ___ YES ___ NO

Please note most companies require a minimum of 60 days prior to the activity start date.

23.Please indicate which date you would like to come present this activity at the next CME Committee meeting,held every fourth Tuesday at noon.

*Please contact Kalen Parks at 725-2128 or two weeks prior to the CME committee meeting toget on the agenda.

Note the following activities are INELIGBLE for AMA PRA Credit:

  • Clinical Experience
  • Charity of Mission Work
  • Mentoring
  • Surveying
  • Serving on a committee, council, HOD, etc.
  • Passing examinations

For CME Office Use Only:

Submitted Proposed CME Activity for Approval:

Date Presented to CME committee:

Approved for CME Activity:

Decided against CME Credit:

Date(s) of Follow-up Emails to Activity Requestor:

Date of Initial Planning Meeting:

Proposed CME Fee:

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