List all other planning/scientific committee members and their affiliation and expertise brought to the committee: Committee Member Expertise Affiliation Queen’s Faculty? Is the planning committee accountable to the head of the department, chief of staff or equivalent? Yes, describe how and to whom accountability is measured for the planning committee: (Box expands as needed) No Will /has the planning committee members demonstrated substantial input by: Yes No Determining selection of all topics Yes No Determining program content Yes No Writing learning objectives Yes No Selecting all speakers/presenters Yes No Ensuring disclosure slides are presented Yes No Reviewing conflicts of interest disclosures and adhering to a plan to mitigate potential biases Yes No Reviewing evaluations Reviewing all presentation materials to: Yes No 1) determine content is evidence based Yes No 2)Medication is referred to by the generic name (tradenames can only be listed if all trade names are included) Yes No 3) Slides / Materials do not follow the corporate colours of any relevant pharmaceutical company or product Yes No Ensuring speakers and program adhere to the Yes No Ensuring speakers and program adhere to the Who is the target audience for this program (select all that apply) Academic Family Physicians Interprofessional teams Researchers Residents & Remote practicing Family Physicians Urban practicing Family Physicians Family Physicians with a community of practice in: Addiction Medicine Cancer Care Child and Adolescent Health Chronic Pain Dermatology Developmental Disabilities Emergency Medicine Family Practice Anesthesia physicians Global Health Health Care of the Elderly Hospital Medicine Maternity and Newborn Care Mental Health Occupational Medicine Palliative Care Prison Health Respiratory Medicine Sport and Exercise Medicine Identify the / roles addressed in this program: Collaborator Communicator Family Medicine Expert / Medical Expert Health Advocate Leader Scholar Professional The program evaluation must include the following questions. Please confirm these have been included: This program enhanced my knowledge (Strongly Agree ….Neutral…Strongly Disagree)
Please indicate which of the CanMEDS-FM /CanMEDs roles you felt were addressed during this educational activity (Collaborator, Communicator, Family Medicine Expert / Medical Expert, Health Advocate, Leader, Professional, Scholar) Did you perceive any degree of bias in any of the program? (No, Yes - Please identify:________) Can you identify any barriers to incorporating what you learned into your practice? The learning objectives of the overall program and specific sessions were met (Strongly Strongly disagree) What learning will you integrate into your practise? Describe the CanMeds roles/competencies for the overall activity and specific sessions as well as how they will be addressed: Overall Program Specific Sessions Please highlight the keywords most relevant to your program from the list below Aboriginal health Academic medicine Addiction medicine Administration Adolescent medicine Allergy Allied health professionals Alternative/complementary medicine Anesthesia and analgesia sciences Behavioural science Cancer care Cardiovascular medicine Cardiovascular surgery Child Abuse Chiropractic medicine Chronic disease management Clinical practice guidelines Communication Community medicine Critical care Culture Dentistry/oral medicine Dermatology Diabetes Domestic Violence Drugs Emergency medicine Endocrinology ENT Environmental medicine Epidemiology Ethics Evidence-based medicine Faculty Development Forensic medicine Family/general practice/primary care Gastroenterology General surgery Genetics Geriatric medicine/care of the elderly Global health Gynecology Health economics Health policy Hematology History Homecare Hospitalist care Imaging techniques Immunology Infectious disease International medicine Laboratory medicine Legal/medico-legal Lifestyle Management Medical careers Medical education Medical informatics Medical students and residents Men’s health Molecular medicine Nephrology Neurology Neurosurgery Nuclear medicine Nursing Nutrition and metabolism Obstetrics Occupation/industrial medicine Oncology Ophthalmology Orthopedic surgery Pain management Palliative care Pathology Patients Pediatrics Pharmacology Pharmacy Preventive medicine Prison medicine Psychiatry Psychotherapy/counseling Public health Radiation therapy Radiology Rehabilitation medicine Religion/spirituality Research methods Respiratory medicine Rheumatology medicine Sexual health and medicine Sociology Sports and exercise medicine Statistics Surgery Thoracic surgery Toxicology Transplant medicine Travel medicine Tropical medicine Urology Vaccines Vascular surgery Women’s health CFPC Quality Criteria Quality Criteria 1: Needs Assessment and Practice Relevance
Participant registration fee Departmental / faculty funding From a not-for profit company Name of not for profit supporter Amount or in kind contribution anticipated or received: From a for profit company Name of for profit supporter Amount or in kind contribution anticipated or received: Describe how will be used; including who is responsible for paying speaker honoraria and travel: Is accreditation/certification for this program sought with any other organization or group? Yes, Name of Organization: ____________________ No Attachments PowerPoint slides, handouts and/or materials for the program Disclosure slides and objectives slides used in the needs assessment /summary of needs assessment findings Program Agenda/ Brochure/Schedule with timing and interactivity labeled Speaker communication template (what instructions are given to speakers) Conflict of Interest forms for the planning committee and speakers Summary of previous event evaluations Copy of program/presenter evaluation form Budget (including revenue and expenses) I __________________ (planning committee chair) confirm that all information in this application is correct and complete. __________________________________ ____________ Signature Date