CONTINUING MEDICAL EDUCATION 100 Woodruff Circle, NE, Suite 331 Atlanta, GA 30322 Phone: 404-727-5695, Fax: 404-727-5667, Email: cme@emory.edu CME ACTIVITY PLANNING AND APPROVAL FORM REGULARLY SCHEDULED CONFERENCES/INTERNAL EVENTS This form is designed to facilitate the planning, implementation, and evaluation of an accredited continuing medical education activity to ensure compliance with the Essential Areas and Standards of the Accreditation Council for Continuing Medical Education. Approval is required prior to the beginning of the Activity. This form should be used to apply for CME credit for Grand Rounds, M&M Conferences, Research Conferences, Tumor Boards, Journal Clubs, and any other education activities in which the target audience is primarily Emory health professionals. ACTIVITY INFORMATION Program Title: This activity is presented by (Department or other entity): Division Of (as applicable): Date(s): Anticipated Location: Smart Key # (required for any charges): Anticipated Registration Fee: Anticipated # of participants: TYPE OF ACTIVITY: (Please check ONE) Course: (conference, symposium, workshop, etc.) – Attach draft agenda with topics and times. Regularly Scheduled Series (RSS)- Frequency: 1/week 2/month 1/month Quarterly Other: Enduring Material - is a non-live CME activity that "endures" over time. It is most typically a DVD, webcast, internet CME. type of activity, please specify: ACTIVITY DIRECTOR: The physician, faculty member, or administrator who will have overall responsibility for the planning, developing, implementing, and evaluating the content and logistics of this activity. Name: Title: Department: Phone: Email: ACTIVITY PLANNING COMMITTEE - List the names, affiliation and emails of persons who participate with the Course Director on the design and implementation of this activity. PLEASE NOTE: Employees of commercial entities are prohibited from participation in planning any accredited CME activity. Name: Affiliation: Email: Name: Affiliation: Check here if additional planning committee members. Attach list. Are any medical students, residents, health professions (not physicians) engaged in the planning or delivery of this CME activity? If yes, please describe:
Physical Therapists Endocrinology Pediatrics Respiratory Therapists Family Medicine Psychiatry Others (specify): Internal Medicine Radiology Neurology Surgery Neurosurgery Urology OB/GYN (specify): Education Format Based on the identified educational needs and desired results, what are the best educational formats for this education activity? Please select all that you intend to use. Competence/ knowledge Performance Patient Outcomes Didactic lectures Hands-on procedural/skills workshops Reinforcing materials such as pocket cards, mobile instruments, etc. Small groups / Panel discussions Interactive case-based presentations Reinforcing activities such as chart audits, hospital QI data review, etc. Demonstrations Simulation lab Other: Interactive (Audience Response System Standardized patient Other: Desirable Physician Attributes Please select all of the core competencies that apply to the content of this activity. ACGME/ABMS Competencies Institute of Medicine Competencies Inter-professional Education Collaborative Competencies Patient care and Procedural skills Provide patient-centered care Values/Ethics for Interprofessional Practice. Medical knowledge Work in interdisciplinary Roles/Responsibilities Practice-based Learning/Improvement Employ evidence-based practice Interprofessional Communication Interpersonal and Communication skills Apply quality improvement Interpersonal and Communication skills Professionalism Utilize informatics Teams and Teamwork Systems-based Practice Other: Outcomes Measurement What type of evaluation method/tool(s) will you use to determine the activity’s effectiveness for achieving the desired results and creating change in the learner’s competence, performance or in patient outcomes? Competence/ knowledge Performance Patient Outcomes Post-activity survey Peer Review / Direct Observation Patient Audits