For Office Use Only:

Activity Code: _______________APPLICATION & CDE/CME ACTIVITY PLANNING FORM FOR JOINTPROVIDERSHIP OF AN EDUCATIONAL ACTIVITYAAOMS CDE/CME Mission Statement (Purpose): The American Association of Oral and Maxillofacial Surgeons (AAOMS)
provides comprehensive, high-quality professional education to Oral and Maxillofacial Surgeons, Oral and Maxillofacial Surgery
residents and other health professionals to improve oral and maxillofacial surgical care for patients and advance the specialty oforal surgery. The AAOMS promotes research and excellence in patient care through its development and implementation of
CDE/CME activities that are timely, evidence-based, and relevant to the needs of its audience. (C1)

General Instructions & Information
The Application for Joint Providership of an Educational Activity must be completed and submitted to AAOMS
Department of Continuing Education staff at least six months (180 days) prior to the presentation date of the
proposed educational activity. All submitted applications must include copies of all required supporting
documentation as noted within the application.
Please download the AAOMS Joint Providership Guidelines and Policies to assist in completing this application.
Fee: A non-refundable fee of $1000.00, in the form of a check payable to the American Association of Oral andMaxillofacial Surgeons, must accompany each application.
Review: Submitted applications will be reviewed by AAOMS staff for completeness. If necessary, AAOMS staff willcontact the applicant to request additional information.
Complete applications will be forwarded to the AAOMS Committee on Continuing Education and Professional
Development for review. The committee will be advised by AAOMS staff if any application for joint providership is in
direct conflict with AAOMS policies or any existing or planned AAOMS educational activity. The CCEPD will review
each application to determine if the proposed jointly provided educational activity meets the American Dental
Association’s definition of Continuing Dental Education as well as the American Medical Association’s definition ofContinuing Medical Education. The CCEPD will also determine whether the topics, goals and objectives of the
proposed jointly provided educational activity are in concert with the AAOMS Continuing Medical and Continuing
Dental Education Mission Statement. Following review of the application, the committee will submit the application,
along with their appropriate recommendation, to the AAOMS Board of Trustees for final review.
Approval: Following review of the jointly provided educational activity application by the CCEPD and the AAOMS
Board of Trustees, one of the following three application statuses will be reached:
1. Approved
2. Approved with modifications
3. DeniedApplicants will be notified in writing (electronically) of the jointly provided educational activity application status.
E-mail is the preferred method of communication. Letters of Agreement will be sent upon AAOMS approval andmust be signed and returned to AAOMS prior to further development of the program.
Please note: Until formally approved by the AAOMS through the process noted above, materials
advertising the proposed jointly provided educational activity may not mention the AAOMS and may notindicate that a continuing education application is pending.
Additionally, joint providership with the AAOMS does not imply that the AAOMS will share in the expenses ofdeveloping, implementing or evaluating the educational activity. Administrative expenses associated with, but notlimited to, the development of educational materials, registration brochures or announcements, evaluation forms,
verification of attendance, etc., are not to be assumed by the applicant organization.
Please e-mail completed applications and requested supporting documentation to:
Shannon Murray, Continuing Education Senior Associate, shannonm@aaoms.org

1General Information
Please provide the following information about your organization.
Please note: The fields within this document will expand to accommodate the information you include and will cause
the text within the document to shift.
Name of organization:
Address:
City:

State:

Zip:

Organization Key Contact Information
Name:
Title:
Mailing address:
City:

State:

Zip:

Phone:
Fax:
E-mail:Please note: Preferred method of communication is e-mail.
Educational Activity Director Contact Information
Name:
Title within organization:
Mailing address:
City:

State:

Zip:

Phone:

Fax:

E-mail:Please complete the information below.
Title of Activity

Start Date/or Publication# of CDE/CME
credits**(Requested)

Expiration Date*
Additional Joint-Providers

Location: (if applicable)(if applicable) (C20)* If course, use the last day of the event. If enduring material, use 3 years from the Publication/Start date.
** Actual number of hours to be determined by the AAOMS Continuing Education Department (1 credit
CDE/CME for every 60 minutes of education)
In addition to this application, please include all the items listed on the Documentation
Requirements Checklist as With the Application. All other items will be required pending approval.

2

For whom is the content designed?
Who is the TARGET AUDIENCE for this activity?

Oral and Maxillofacial Surgeons
Oral and Maxillofacial Surgery Residents
General Dentists and/or other dental specialists
OMS Staff – clinical or professional
Other (please describe): _____________

What is the EDUCATIONAL REACH for this activity?

Local (city and/or suburbs)
State (within host state boundaries)
Regional (several states in geographic area)
National
Other (please describe): ______________

Format and Educational Methodology (C5)In what way(s) are the format and teaching methodologies appropriate for the setting, objectives, and desired results ofthis activity?

Select the Activity Type/Format:
Live Activity – oral surgeon/physician must attend in person or virtually to claim credit (i.e. course, lecture, discussion, hands
on workshop, examination, live webinar or teleconference)

Enduring material – printed, audio, video or on-line activities that can be used over time at various locations (i.e.
monograph, invited review, course book, case studies, archived recording)

Journal-based CME – identified article within a peer-reviewed, professional journal
New Procedures – skills course training oral surgeon/physicians on topics that allow them to request new or expanded
privileges (i.e. surgical or new medical devices) (4 skill levels of training required to qualify)

Test Item Writing – for high stakes examinations
Manuscript Review - for Journal Editors and Editorial Board members
Performance Improvement – structured, long-term process
Internet Point of Care Learning – structured, self-directed online learning
Other – (i.e. learning plans)Please describe why this format is appropriate for this activity:

The educational methodologies include:
LectureCase Presentations
Test Questions (including pre-and post-tests)
Small Group/Roundtable Discussion
Simulation
Interactive Online Elements (Specify: ___________________)
Other (Specify: ___________________)

Desirable Attributes (C6)Which desirable attributes (competencies) in oral and maxillofacial surgeons are addressed in the content of this activity?
Check all that apply, and provide an example for each one selected.

Adapted from the Six Core Competencies for Quality Patient Care identified by ACGME/ABMS
Patient Care that is compassionate, appropriate, and effective for the treatment of health problems andthe promotion of health.
Medical/Dental Knowledge about established and evolving biomedical, dental, clinical and cognate sciences
and their application in patient care.
Interpersonal and Communication Skills that result in effective information exchange and teaming withpatients, their families and professional associates (e.g. fostering a therapeutic relationship that is ethicallysound, uses effective listening skills with non-verbal and verbal communication; working as both a teammember and at times as a leader).
Professionalism as demonstrated through a commitment to carrying out professional responsibilities,
adherence to ethical principles and sensitivity to diverse patient populations.
Systems-based Practice as demonstrated through an awareness of and responsibility to larger context
and systems of healthcare, and the ability to call on system resources to provide optimal care (e.g.
coordinating care across sites or serving as the primary case manager when care involves multiple specialties,
professions or sites).

3

Practice-based Learning and Improvement that involves investigation and evaluation of their own patientcare, appraisal and assimilation of scientific evidence and improvements in their medical/dental practice.
Institute of Medicine Competencies: Provide Patient Centered Care
Institute of Medicine Competencies: Work in Interdisciplinary Teams
Institute of Medicine Competencies: Employ Evidence-Based PracticeInstitute of Medicine Competencies: Apply Quality Improvement
Institute of Medicine Competencies: Utilize Informatics
Interprofessional Education Collaborative Competencies: Value/Ethics for Interprofessional
Practice
Interprofessional Education Collaborative Competencies: Roles/Responsibilities
Interprofessional Education Collaborative Competencies: Interprofessional Communication
Interprofessional Education Collaborative Competencies: Teams and Teamwork

What is actually
happening

The GAP(What is the underlying problem or
issue in practice that you want toaffect/change with this activity )What is optimally supposed tohappenUse additional pages if necessary. The purposes of this form is to link each gap identified to need for thiseducation to each objective to the outcome being measured

Current Practice
What is the current practice of OMSs, and if applicable additional target audience members?

Better or Best Practice
What is the current standard of care for the topic area? (as defined by AAOMS or otherguideline/documentation) What should OMSs and if applicable additional target audience members be doing?

What is the Gap in Learning?
(Based on the current practice vs. the best practice?)

Learning Objectives
What is this educational activity designed to change?
List the learning objectives for this activity, as well as how each objective addresses the educational need(s)identified. Use action verbs and specific criteria (see below) in order to measure whether or not theobjectives were achieved and the professional practice gap was closed. Also indicate the type of change(competence, performance, or patient outcomes) that is associated with each learning objective.
PLEASE NOTE: A statement of learning objectives is NOT the same as a course description, but thepathway that takes the learner from the identified need to the desired result. Objectives must be measurable
and stated from the perspective of what the learner will be expected to implement in his or her practice.
Example:Upon completion of this activity, the learner will be able to:4

Provide a wide variety of treatment options and ensure a safe environment for patient care.
Educational need(s) addressed by this objective:
OMSs need to provide safe environment for patient care.
Type of change:
Knowledge

Competence

Performance

Patient Outcomes

Knowledge – having information
Competence – knowing how to do something (e.g., skills, abilities, strategies) which has not yet been put into
practice
Performance – the skills, abilities, and strategies one implements in practiceLearning Objective
Learning Objectives should be directly tied to the underlying educational need. These objectives should bespecific and measureable and aim to address the identified practice gap.
Examples of activity verbs can be found below.
To describe changes in Knowledge/Competence, consider using: Analyze, Assess, Classify, Compare, Define, Describe,
Differentiate, Discuss, Distinguish, Estimate, Explain, Examine, Evaluate, Identify, Indicate, Label, List, Name, Outline,
Predict, Recall, Recognize, Record, Relate, Review, State, Summarize
To describe changes in Performance, consider using: Apply, Arrange, Assemble, Calculate, Categorize, Choose, Collect,
Combine, Complete, Construct, Create, Demonstrate, Design, Develop, Devise, Employ, Formulate, Illustrate, Interpret,
Model, Modify, Operate, Organize, Plan, Prepare, Produce, Select, Use, Utilize
To describe changes in Patient Outcomes, consider using: Change, Detect, Discover, Enhance, Generate, Impact,
Improve, Realize
AVOID the following vague or ambiguous verbs: Appreciate, Believe, Comprehend, Conceptualize, Experience, Feel,
Hear, Know, Listen, Memorize, Perceive, See, Think, UnderstandLearning Objective 1
Upon completion of this activity, the learner will be able to:

Educational need(s) addressed by this objective:

Type of change:
Knowledge

Competence

Performance

Patient Outcomes

Learning Objective 2
Upon completion of this activity, the learner will be able to:5Educational need(s) addressed by this objective:

Type of change:
Knowledge

Competence

Performance

Patient Outcomes

Learning Objective 3
Upon completion of this activity, the learner will be able to:

Educational need(s) addressed by this objective:

Type of change:
Knowledge

Competence

Performance

Patient Outcomes

Indicate the method(s) or source(s) used to identify the professional practice gap and the underlying
educational needs addressed by this activity: (Check all that apply. Documentation is required.) (C2 and C3)
Evaluation of previous CDE/CME activities

New advances

Expert opinion (i.e. minutes or meeting report)

Review of clinical data

Focus group

Review of performance; peer review

Literature research

SurveyMorbidity and mortality statistics

Test of knowledge

Other:

Please check the major content areas, and provide any additional information as needed. (C4)
Included in
activity

Content Area (AAOMS Parameters and Pathways)

Additional Information

Patient Assessment
Anesthesia in Outpatient Facilities
Dentoalveolar Surgery
Dental and Craniomaxillofacial Implant Surgery
Surgical Correction of Maxillofacial and Skeletal Deformity
Cleft and Craniofacial Surgery

6Trauma Surgery
Temporomandibular Joint Surgery
Diagnosis and Management of Pathologic Conditions
Reconstructive Surgery
Cosmetic Maxillofacial Surgery
Other (please list)
Other (please list)

Who are the EXPERTS (FACULTY / AUTHORS) who would best present this information? (C7 and C9)*
Faculty/Author(s)Name(C7 and C9)Disclosure
Recv’dMitigated

Disclosure
Recv’dMitigated

List here who will
tentatively be providing
the CDE/CDE/CME
content and presenting
the material* Actual faculty,
disclosures, and relevant
financial relationships
mitigated will be
required as part of yourfinal materials submitted
to CE staff

Who are the individuals who contributed to the content& what is their role (committee, staff etc)?
List all others
involved incontent decisions
for this activity(committee
members, staff,
board, etc)

Name

(C7 and C9)

Submit faculty/planners separately, if necessary

7Will funding/in-kind donations from COMMERCIAL SUPPORT be requested? (C7-C10)
Any commercial supporters (in kind or monetary) will need to complete a letter of agreement (LOA). A
sample LOA can be found here. All signed copies of letters of agreement will need to be submitted to the
Department of Continuing Education prior to the start of the activity.
No
Yes
Single company
Company Name

Multiple companies (If multiple, please list)
Company Name

In-kind donations (If multiple donors, please list)
Company Name

Letter ofAgreement
Recv’dFunding
Recv’dLetter ofAgreement
Recv’dFunding
Recv’dLetter ofAgreement
Recv’dType of
Equipment
Recv’dDurableEquipment
Facilities/
Space
Disposablesupplies (nonbiological)
Animalparts/tissue
Humanparts/tissue

How do you plan to MEASURE THE DESIRED RESULTS? (C11) (Activity Evaluation)(i.e. Survey data, Focus Groups, Pre-Post Test)
What changes (knowledge, competence, performance, patient outcomes) are proposed to be achieved as aresult of this educational activity?
Methods used to determine the activity’s effectiveness in meeting identified educational needs andobjectives for which it was designed (check as many as apply):
Methods of
Evaluation
Pre-/Post-Testing
without clinicalvignettes
Pre-/Post-Testingwith questions
containing clinicalvignettes
Post-activity
Evaluation (required)
Expert Observation ofProcedure Skills
6-8 week Follow-up
Survey (required)
Other (specify)

Knowledge

Competence

Performance

Patient Outcomes8

Accreditation with Commendation
There are 16 commendation criteria, divided into five categories:• Promotes Team-based Education• Addresses Public Health Priorities• Enhances Skills• Demonstrates Educational Leadership• Achieves Outcomes
If you feel your activity could apply to one of these criteria in the wheel below please check here.
A CE staff person will be in touch with you for more details.

For Office Use Only:

Committee Review (C22)
Committee reviewed

Review date

Decision9Documentation Requirements and Checklist
As of January 2023

The following documentation must be submitted along with the completed application.
Please use this page as a checklist to ensure that you have collected all required documentation or have included itin the form.
With Application:
A copy of your continuing education mission statement.
Minutes of all planning meetings held to-date in which development of the educational activity is
discussed.
Disclosure of relevant financial relationship statements from all individuals involved in planning theactivity including staff members, and mitigation forms. (Forms attached)
A summary of the needs assessment conducted for the activity.
A synopsis of the presentation material for the activity.
Learning objectives for the activity.
Proposed program outline/schedule/agenda for the activity with presentation timing clearly noted.
Proposed list of faculty (speakers) with professional affiliations, clinical designations and a copy of
their most recent CV or biographical sketch.
Copy of the proposed evaluation form for the activity. (sample questions available)
Copies of draft promotional materials for the activity (if available).
Proposed budget for the activity.
After Approved:
Copies of all draft promotional materials for the activity for approval of accreditation and credit
designation statements.
Copy of Transcript or Certificate
Copy of Handout/Session Materials to approve disclosure listing
The final draft evaluation form for the activity.
Copies of all Letters of Agreement (LOAs). Dually-signed (AAOMS and commercial supporter) prior
to the activity taking place.
After the Activity:
A copy of your final evaluation data. (Sample summary provided below)
Your final registration list with attendee credentials included (need to know number of MDs and nonMDs).
Copies of all final marketing materials.
Final CDE/CME activity budget. Including all revenue from tuition/registration fees,
advertising, or commercial support, and all expenses (e.g., payments to authors, design andtechnology costs)
Three month follow-up survey results, measuring attendees’ changes in learning as stated intheir evaluations.

1Required Documentation Descriptions
1.

Continuing Education Mission Statement: This is a statement describing your organization’scommitment to and reasons for providing continuing education to your constituent groups. So long as it
adequately describes your organization’s educational mission, this statement can be as short as one
paragraph or as long as several pages.

2.

Planning Meeting Minutes: Minutes of your organization’s planning meeting minutes provide AAOMS
with information regarding the direction planning for your educational activity has taken prior to your joint
sponsorship application submission. These minutes will also provide information pertaining to theassessed need for your activity. AAOMS need not obtain a complete copy of the minutes for eachplanning meeting that has taken place – only minutes for those meetings in which discussion of youractivity has taken place. Your meeting minutes may also be excerpted to include only the pages indicating
the date, location and participants involved in the meeting as well as the page(s) noting the activity
planning discussion that took place.

3.

Disclosure and Mitigation of Relevant Financial Relationship Statements: In accordance with theguidelines and policies set forth by the Accreditation Council for Continuing Medical Education, allindividuals who have the opportunity to guide and influence the development of an educational activity
must disclose any relevant financial relationships they may have. This extends beyond the speakers who
may participate in the activity to the planning committee members and organization staff who develop theeducational activity. Disclosure of this information must be provided along with the joint providership
application so that AAOMS can determine if appropriate planning for the activity has occurred prior to
AAOMS involvement. Any relevant financial relationships will also need documentation included of how
they were mitigated.

4.

Summary of Needs Assessment: A summary of any data collected by your organization that indicatesthe need to provide the planned educational activity to your organization’s constituent groups. This can bedata obtained through an educational survey or comments received through evaluations of previous
educational activities, etc.

5.

Presentation Synopsis: This is a brief paragraph highlighting the detailed information to be provided
through the educational presentation(s).

6.

Learning Objectives: Learning objectives are the pathway between the assessed need for theeducational activity and the desired result of the educational activity. Learning objectives should begin
with a descriptive action word such as “discuss”, “describe”, “explain”, etc. and should complete thephrase, “At the conclusion of this activity, participants should be able to:”7.

Program Outline/Schedule/Agenda: Please provide an outline of the planned educational activity
including the specific presentation titles and the timing of the presentations, breaks, lunch, etc.

8.

Faculty List: Please provide a listing of the proposed faculty (speakers) for your educational activity. This
list should include their professional/academic affiliations, their clinical designations (DDS, MD, etc.). This
information can be provided as part of the program outline for your activity where each faculty member islisted along with the presentation(s) they are scheduled to deliver. Please also provide a copy of eachfaculty member’s most recent CV or biographical sketch.

9.

Proposed Evaluation Form: This is a copy of the mechanism your organization and your activity
participants will use to evaluate the activity upon its completion.

10.

Promotional Materials: If your organization has drafted promotional materials for your planned activity,
please provide copies of these materials for review along with your application.

11.

Proposed budget: Your organization’s proposed budget for the activity is requested to determine if theplanned activity is appropriately funded.

2

Sample Evaluation Summary
To be answered after the activity has been implemented with the assistance of AAOMS Staff
Percentage of learners reporting that they detected inappropriate promotion of a commercial product, device,or service (Post-activity Evaluation, Q. ?). _____________ %Comments from learners:
If applicable, how was this bias addressed, resolved, and considered as part of future planning?

Learners demonstrated a change in competence as follows (aggregate comparison of Pre- and PostTest scores): (if applicable)
Average Pre-Test Score

Average Post-Test
Score

Question 1

Change +/-Question 2
Question 3
Question 4
Question 5

Learners reported improved competence or performance as follows (Post-activity Evaluation, Q. 1):
Objective 1

To a great extent

To some extent

To a little extent

Not at all_____ %_____ %_____ %_____ %_____ %_____ %_____ %_____ %_____ %_____ %_____ %_____ %

Objective 2
Objective 3

Achievement of desired results and measurement of outcomes:
Desired Results
Desired Change in Competence

How was this measured?

What was the outcome?

Desired Change in Performance
Desired Change in Patient
Outcomes

Activity Evaluation (C11)

What changes (knowledge, competence, performance, patient outcomes) were achieved as a result of this educational
activity?

Based on the data above, explain how this activity met identified educational needs and closed theprofessional practice gap.

3