Application For Continuing Medical Education Activity

APPLICATION FOR SPONSORSHIP Public Health Consortium for Continuing Medical Education OF A CONTINUING MEDICAL University of Michigan School of Public Health Office of Public Health Practice EDUCATION ACTIVITY 109 S. Observatory, Ann Arbor, MI 48109-2029 Phone: 734-763-6526 Fax: 734-764-9293 VERSION A: Email: [email protected] USE FOR FACE-TO-FACE OR LIVE WEBCAST ACTIVITIES. phc-cme.org

To fulfill the requirements of the Public Health Consortium for Continuing Medical Education, which is accredited by the Michigan State Medical Society, the following information is necessary for the activity to be eligible for AMA/PRA Category 1 credit.

Activity Title:

Activity Date(s)/Location(s):

Number of AMA PRA Category 1 Credits Requested:

Sponsoring Organization (PHC member):

Activity Liaison:

Email Address: Phone: Fax No:

Mailing Address:

Activity Coordinator:

Email Address: Phone: Fax No:

Mailing Address:

Activity Partner(s) – other organizations involved with this activity:

Type of Activity: Course (symposium, workshop, regularly scheduled conference, etc.) (Check all that apply.) Live webcast Other, please specify:

Anticipated Number of Attendees:

Identify Specialties (Target Audience): Public health/preventive medicine physicians (Check all that apply.) Primary care physicians Veterinarians Dentists Other, please specify:

Revised 3/07 Page 1 of 7 Target Audience—Scope: FORMCHECKBOX Internal Consortium organization audience, please specify: Local/regional, please specify: National/international (CME credit can be award only to physicians with a Michigan license.)

Activity Program/Schedule: Include copy of the proposed program as Attachment 1. The program must include:  Start and end times for each presentation or activity including breaks and meals  Accreditation and Designation Statement  Learning Objectives  Target audience

Unless the program clearly specifies detailed information for each presentation, also include an activity schedule here or as part of Attachment 1. Provide for each presentation for which you seek CME credit: 1) Title, 2) Speaker(s), 3) Length of presentation, 4) Number of CME credits requested 5) Is this a Q&A session or panel discussion? (Note that CME credits are designated to the nearest quarter of a credit.)

Needs Assessment: How have you identified the educational needs of your target audience? (Check all that apply.) Needs assessment documentation is Attachment 2. For example if "Literature Search," provide a copy of work done. Application will not be processed without documented needs assessment.

Expert resources (faculty) Library Requests from intended audience… New medical information Literature search Prior course/conference evaluations PUBMED Referral experiences Other (specify) Survey of target audiences Prior conference evaluations Focus group data Quality improvement data (specify): New medical knowledge or technology Institutional/organizational requirement (specify): Other method (specify):

Identified Needs: List/describe the educational needs to be addressed by this CME activity. Here you are being asked for the analysis you have done of your needs assessment data. (Note that these identified needs are the basis for your educational objectives for your activity.)

Revised 3/07 Page 2 of 7 Planning Committee Members: The Activity Liaison must be a member of the planning committee. List below all persons planning the program. A "Conflict of Interest/Disclosure of Commercial Relationships" form must be submitted for each planning committee member. Include as Attachment 3.

If conflict of Planning committee member(s): provide name, degrees, title, organizational affiliation interest/commercial relationship has been disclosed, check here. 1. 2. 3. 4. 5. 6. 7. 8. (If more than eight members, attach a table and include with Attachment 3.)

Planning Process: Please provide description or documentation for the process used to develop the educational objectives of this activity? Minutes of planning committee meetings attached (Attachment 4.) No formal planning committee meetings were held. Planning process is described here:

Statement of Educational Objectives: These objectives are designed to meet the educational needs of the physician audience. If more space is required, include as Attachment 5. (Note that educational objectives must be included in the program and on the evaluation.) Complete.

Following participation in this activity, participants should be able to: (Please number or use bullet point format.) 

Educational Design: What presentation method(s) do you intend to use? (Check all that apply.)

Lecture (didactic) Video/Interactive Post Q/A Demonstrations Panel discussion Skills workshops Small group discussion Case discussion/study (MUST BE HIPAA-COMPLIANT) Other/additional format (specify):

Content: (Attachment 6). Provide a short description of the content of each presentation for which CME credit is sought. These descriptions can be from your proposed program, as long as more than a title is provided.

Revised 3/07 Page 3 of 7 Speakers: List below all speakers for proposed CME presentations. For each speaker, a "Conflict of Interest/Disclosure of Commercial Relationships" form and a "Biographical Data" form must be submitted. Speaker data are Attachments 7and 8. Include "Conflict of Interest/Disclosure of Commercial Relationships" forms as Attachment 7. Biographical data must include name, degrees, title, department and institutional affiliations, area(s) of expertise and qualifications related to the presentation. Include as Attachment 8. (Please do not include more than one page of biographical data per speaker.) Speaker(s)/presenter(s): If conflict of interest/commercial relationship has been disclosed, check here. 1. 2. 3. 4. 5. 6. 7. 8. (If more than eight speakers, attach a table and include with Attachment 7.)

Conflict of Interest/Commercial Relationship Disclosure: Conflict of interest/commercial relationships for speakers and planning committee members (or lack thereof) must be disclosed to the audience prior to the beginning of the educational activity. Identify the disclosure method you intend to use. (Documentation about your disclosure method must be included with after program requirements.) Means of disclosure of conflict of interest/commercial relationship (or lack there of): Prior to educational activity in a printed announcement, PowerPoint slide, or similar vehicle In conference materials (program, syllabus, or faculty listing) distributed prior to presentations Disclosure statement displayed at sign-in table or on sign-in sheet

Evaluation: PHC CME policy requires that the evaluation tool measure the goal of whether course objectives were met and whether there was commercial bias in the presentation(s). Course objectives must be listed on the evaluation tool. In addition, the evaluation tool must include questions:  "How well were the objectives of the presentation met?"  Question on the quality of the instructional process  Question on the perceived enhancement of professional effectiveness

Advisory: If conflict of interest has been identified for a speaker, consider adding a question to evaluate whether participants have perceived bias. E.g. "Were any presentations commercially biased in any manner? No Yes, please explain."

Document how the activity will be evaluated and attach a copy of the evaluation tool (Attachment 9) to be used for this activity. Standardized evaluation form Pre/Post tests Self-Assessment form Other:

Budget: Attach copy of your proposed budget as Attachment 10. (Note that a final itemized budget must be submitted as part of the after-program requirements upon completion of this activity.) This program will be funded by (check all that apply): Registration Vendor/Commercial support (Complete next section.) Originating organization’s cost center Other:

Revised 3/07 Page 4 of 7 Commercial Support: The Public Health Consortium (PHC) adheres to the Standards for Commercial Support of the ACCME and MSMS. The PHC reserves the right to deny approval of commercial support.

Any commercial support obtained by the applicant organization must be declared in the initial application and completed Commercial Support Agreement (CSA) Forms must be submitted. See the PHC CME Policy and Procedure Manual (revised January 2007) for additional information non what constitutes commercial support.

Is commercial support being provided for this activity?

No Yes. Complete commercial supporter information below and include signed (CSA) forms as Attachment 11.

Commercial Supporters:

1. Company Name:

Representatives’ Name: Phone:

2. Company Name:

Representatives’ Name: Phone:

(Attach separate sheet if more space is needed.)

Means of Disclosure of Commercial Support to Participants: In a (printed) announcement/brochure or on sign-in sheet Disclosure statement displayed at sign-in table or a poster Not applicable (no commercial support)

Accreditation/Credit Designation Statement

Promotional Materials: You may not refer to CME certification on any promotional document until your activity is approved by the Public Health Consortium. Specifically, you may not state that CME credit has been applied for.

Upon approval, all promotional materials must include the following credit statement verbatim, with your organization's name and number of credits inserted where indicated. Any printed or electronic announcement, if it references the maximum number of credits for which the provider has designated the activity, must clearly indicate the complete Designation Statement. An announcement with limited space may indicate that CME credit will be provided without stating an exact amount; use the statement, "This activity has been approved for AMA PRA Category 1 Credit."

Complete Designation Statement: “This activity has been planned and implemented in accordance with the Essential Areas and policies of the Michigan State Medical Society Committee on CME Accreditation through the joint sponsorship of the Public Health Consortium and (name of the PHC Organization). The Public Health Consortium is accredited by the Michigan State Medical Society Committee on CME Accreditation to provide continuing medical education for physicians.

The Public Health Consortium designates this activity for a maximum of [number of hours] AMA PRA Category I Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Revised 3/07 Page 5 of 7 Credit Certificates: Include as Attachment 12. AMA PRA Category 1 Credit certificates for physicians should read as follows:

The [name of PHC Organization] certifies that [name of physician] has participated in the educational activity titled [title of activity] at [location, when applicable] on [date] and is awarded [number of credits] AMA PRA Category I Credit(s)TM.

Certificates of Attendance: Include as Attachment 12, should you choose to issue non-physician health professionals a certificate of attendance which references AMA PRA Category 1 Credit. Certificates of attendance for non-physicians are not subject to a processing fee. Attendance certificates for non-physicians participants can read:

The [name of PHC Organization] certifies that [name of participant] has participated in the educational activity titled [title of activity] at [location, when applicable] on [date]. This activity was designated for [number of credits] AMA PRA Category I Credit(s)TM.

Application Checklist: Pre-Activity (submit with application) (Required attachments in bold)

Program/schedule (1) Needs assessment documents (2) Planning committee members COI (3) Planning meeting minutes (4) Educational objectives (5) Program content brief descriptions (6) Speaker COI/commercial relationships disclosure forms (7) Speaker biographical data forms (8) Evaluation (9) Proposed budget (10) Commercial support agreements (11) Sample certificates (12)

Fee: Due with this application is a fee of $100, submitted as: Check. Make check payable to the University of Michigan. Include the shortcode "412888" on check. Journal entry (shortcode "412888"). Available option for University of Michigan entities. Include JE with application.

Credit cards and purchase orders are not accepted at this time.

Revised 3/07 Page 6 of 7 Application Procedure: This form must be complete and submitted no later than six weeks prior to the quarterly Public Health Consortium Advisory Committee meeting. Notice of certified AMA PRA Category 1 credit will be sent to the Activity Coordinator after review and approval of the program at the next meeting of the Advisory Committee.

Please return completed application, attachments and fee to Continuing Education Coordinator, Office of Public Health Practice, University of Michigan School of Public Health, SPH I Crossroads, Room 2669, 109 Observatory, Ann Arbor, MI 48109-2029. Application and/or attachments may be submitted electronically to [email protected].

Submitted for Category 1 Credit

By signing this application form, the Activity Coordinator acknowledges that the information provided is accurate. If the application is approved, the Activity Coordinator agrees to submit After Program Requirements within 30 days of completion of the activity.

______Date Submitted Signature: Activity Coordinator

FOR CME OFFICE USE ONLY

______Application received/ Assigned # ______

______Date of committee meeting

_____ Approved for ______hours Category 1 American Medical Association Physician's Recognition Award credit (AMA/PRA) _____ Not approved

PHC Staff: ______(initial here)

Revised 3/07 Page 7 of 7