Where to Submit

STEP III APPLICATION FORM FOR MOC Section 1 ACCREDITED GROUP LEARNING ACTIVITIES CNSF Congress Co-Developed Symposium

To qualify for Section 1 MOC Credits  The Activity needs to be developed or co-developed by a physician organization.

 The Chair of the planning committee is to be selected by the CNSF.

 The planning committee must be reflective of the target audience.

 Learning activities are created based on needs as identified on CPD surveys of the target audience.

 Needs assessments from past CNSF CPD Events, related to a specific topic (e.g. Epilepsy), must be utilized by the planning committee.

 Planning process is to be in the control of the profession to ensure no undue influence of commercial interests and to ensure that content meets the highest standards of academic integrity and balance.

 The planning committee is responsible for identifying topic, audience, learning format, learning level, learning objectives, and CanMED roles.

 CNSF will be responsible for providing past CNSF Congress Needs Assessments and CPD Evaluations, templates for disclosure forms and statements, templates for Course Notes, evaluation forms.

 Learning objectives are provided from the learners’ perspective.

 The Activity integrates didactic and interactive learning strategies.

 The Activity utilizes 25% interactive learning.

 Content presented is evidence-informed and meets the highest standards of academic integrity.

 The Planning Committee, representing the target audience, is to ensure the scientific content within the Course Notes and the presentation is not biased and is evidence-based.

 Courses Notes are to be approved by the CNSF to ensure there is no undue influence of commercial interests including, but not limited to: placement of logos, co-developed statement, use of colors (e.g. drug colors may not be used in the promotion of an educational event), other subliminal messaging.

 We will evaluate:

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 1/30 updated October, 2015 STEP III o Were Learning Objectives met?

o Was content perceived as balanced and free from conflict of interest?

o Was time to reflect on learning provided?

o Was sufficient time for interaction provided?

CNSF Contact Information For information on continuing professional development and MOC Applications and for information on CJNS/ Congress advertising, recording of symposia session, sponsorship, etc

Dan Morin – CEO (403) 229-9544 or [email protected]

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 2/30 updated October, 2015 STEP III

CNSF Congress and CJNS Advertising Deadlines October 31, 2015 CEO and Industry negotiate agreement for Co-Developed Events November 2015  The Chair of the planning committee is to be selected by the CNSF. Symposium Chair must be a CNS or CNSS member in good standing. o Non-members are not permitted to sit as a Symposium Chair of CNSF Co- Developed events. o To assist the process, upon request of Industry, the CNSF will check the Membership database prior to Industry contacting a potential Symposium Chair.  Symposium Chair is responsible for: o Completing and signing the MOC Application. o Selecting the Planning Committee. IMPORTANT NOTE: Industry Representatives cannot be part of Planning Committee. Industry’s role is limited to logistical planning. CNSF PDC Representative sits on Planning Committee as an observer, not an active member of the planning process. See page 2 for additional information on role of the CNSF PDC Representative. November 2015 CNSF to contact Industry representative (or designate) by email to provide:  Co-Developed Symposium Checklist to be completed upon the Symposium Chair accepting position. December 1, 2015 Video & Audio Recording of Co-Developed Sessions  If Industry is interested in recording a Co-developed session, for their own use and for inclusion within the CNSF website agreements must be in place prior December 1st as logistical, faculty and participant considerations must be taken into account during the planning stage.  Please contact Dan Morin as part of negotiations for the Co-Developed session. December 1, 2015 SYMPOSIUM DEADLINE  Co-Developed Symposium Checklist to be submitted to Dan Morin at dan- [email protected]

Upon Receipt of CNSF to: Co-Development Checklist  Assign a CNSF PDC Representative to sit on the planning committee.  Begin the process of recruiting an Accreditor.  Forward the Symposium Chair and PDC Representative information including, not limited to: o MOC Application Form, o Online links to changes to MOC application process, resources for Chairs and Speakers, CPD toolkit. o Past CNSF Membership Needs Assessments. o Samples of evaluation forms used by CNSF. March 1st 2016 SYMPOSIUM DEADLINE Last day to submit MOC (Co-developed) Application to CNSF. Please ensure inclusion of:  MOC Application  Detailed Agenda (also called Activity Schedule, including Learning Objectives)  Detailed Budget  Evaluation Tool  Disclosure Forms from Planning Committee, Moderator, Speakers  Disclosure Statements (draft acceptable)  Draft of Advertising and other Printed Materials If drafts not available include following statement “Drafts of Advertising and other printed materials not available at time of MOC Application deadline. It is

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 3/30 updated October, 2015 STEP III understood that all advertising and printed Materials must be approved by the CNSF, prior to dissemination.”  Electronic MOC Applications sent to CNSF should include Symposium Chair, CNSF PDC Representative, CHE Coordinator  Once a MOC Application is submitted, only the programs included in the application may be included within the Final Program. Addendums to the Final Program will not be allowed. IMPORTANT NOTE TO INDUSTRY: Once an Application is received up to 6 weeks is required for processing. April 10, 2016 CNSF Submits its MOC Application IMPORTANT NOTE TO INDUSTRY: Co-developed Learning Objectives must be included in submission. Please ensure that your MOC Applications are submitted by March 1, 2016 to ensure learning objectives are part of the overall CNSF MOC Application. May 1, 2016 Co-Developed Invitation Mailout  Deadline for CNSF invitation mail out to Membership  Please include a pdf of the invitation for inclusion on the CNSF website. IMPORTANT NOTE TO COLLABORATING PARTNERS: Industry to provide the CNSF invitations for distribution to CNSF membership. Invitations require prior approval by the CNSF. May 1, 2016 SYMPOSIUM DEADLINE Material Samples (posters, handouts, etc.) Industry must provide a sample of all materials in final form to the PDC Representative and Professional Development Coordinator for Final Approval. For detailed information see page 7. May 8, 2016 SYMPOSIUM DEADLINE  To ensure faculty are paid, Industry to provide cheques for honoraria to the CNSF no later than the 2nd Friday in May. June 21 – 24, 2016 CNSF Annual Congress Fall 2016 CNSF to provide Industry with feedback received on the Symposium through Congress Evaluations.

CNSF Co-Developed Symposia Goals The goal of the CNSF, when creating Co-Developed Symposia, is to provide Congress delegates with access to relevant information on patient care, within a transparent environment.

To accomplish this goal CNSF Co-Developed Symposia will:  Acknowledge Co-developed partners.  Provide physicians/ surgeons with access to a relevant learning activity to assist them with enhancing the care of patients with neurological conditions.  Create a balanced and unbiased representation of the benefits, risks, appropriateness of all products related to patient care.  Create a current, evidence-based, learning activity to maintain, develop or increase knowledge, skills, and the competency of physicians/ surgeons on the advances of a disease within a specialty/ subspecialty.  Organize scientific and logistical planning for the symposium which is conducted in a professional and ethical manner based on shared health values and mutual respect.  Provide variety in co-developed learning activities by inviting 2 or more speakers in addition to the moderator/ chair.  Ensure the learning activity includes, but is not limited to, the following principles of adult learning: o Target Audience is comprised of neurologists and/or neurosurgeons, and this audience is represented within the planning committee.

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 4/30 updated October, 2015 STEP III o A Needs Assessment is conducted or available, representing the learning needs of the target audience. o Learning Objectives are provided, from the perspective of the target audience. o Integrates didactic and interactive learning strategies. o At least 25% interaction between the audience and speakers is incorporated within the learning activity. o A final course evaluation is provided evaluating, at a minimum, if: . Learning Objectives were met. . Content was perceived as balanced and free from conflict of interest. . There was time to reflect on learning provided. . There was sufficient time for interaction provided.

Helpful Hints for Conference Organizers of Co-developed Symposia

Disclosure Forms and Statements (See Schedule A of MOC Application) Submit Disclosure Forms to the CNSF. Include a disclosure statement on Slide 3 of presentation. For samples, view the online CPD Toolkit. See Schedule C.

Free of Bias, Conflict of Interest and Self-Promotion Scientific content is to be perceived as balanced and free from conflict of interest, with no self-promotion of an individual, product or organization.

Honoraria for Chairs, Speakers, Moderators See Schedule D.

Budget See Schedule E.

Materials for Approval Industry must provide a sample of all materials in final form to the CNSF Secretariat for Final Approval. See Schedule G.

Power Point Presentations We encourage the Planning Committee to provide their Power Point presentation no later than May 1st for inclusion within the 2016 Congress Online Course Notes. Recognizing that speakers are busy if a Power Point presentation is not possible to submit for May 1st, we can provide an alternative Word template which may be submitted in lieu of the PowerPoint.

Industry is encouraged to provide PowerPoint Presentations onsite as either: (1) hard copy handouts, (2) on a CD or USB drive. See our CPD Toolkit for effective Power Point presentation hints.

Sign-in Sheets See Schedule H.

Certificates of Participation The CNSF does not print individual Certificates of Participation. Co-developed symposiums are included on the CNSF Annual Congress Certificate of Participation and are disseminated in July 2016.

Advertising The CNSF trusts that the marketing department or agency of our Collaborative Partners will use their best judgment and experience to create non-biased advertisements which will not be perceived as influencing the prescribing practices of physicians, while still encouraging delegates to attend the Co-Developed Symposium. See Schedule F.

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 5/30 updated October, 2015 STEP III Accreditation Statement Can only be used once the MOC Application is approved by the CNS/ CNSS Accreditor.

Acceptable Verbiage and Logo– Prior to Accreditation Typically placed as a footer: This event will be reviewed for Section 1 MOC credit by the Canadian Neurological Society/ Canadian Neurosurgical Society. With CNS/ CNSS logo on left and industry logo on right or with CNS/ CNSS logo on top of the industry logo

Acceptable Verbiage and Logo – After Accreditation Approval Typically placed as a footer with CNS/ CNSS logo on left and industry logo on right or CNS/ CNSS logo on top of the industry logo. The Accreditation Statement will be provided by CNSF in an official letter after approval granted for Section 1 MOC credit. Accreditation Statement - Typically located in centre of two logos if left/ right logo placement.

Unacceptable Verbiage Unrestricted education grant, Satellite Symposium

Video/ Audio Recording of Symposium See Schedule I.

Logistical Considerations See Schedule L.

Room Logistics  The CNSF strongly encourages organizers to keep food in the room your session is in to minimize confusion of delegates not attending event.  Though this may reduce the total capacity for attendance in the room it will provide Congress delegates and your Congress Management Team with a smoother transition between sessions.

Co-Developed MOC Application

The CNSF Accreditation of Activities for Section 1 (Group Learning Activities) On January 1, 2001, the Royal College of Physicians and Surgeons of Canada established the Maintenance of Certification activity. Participation in the Maintenance of Certification activity is a requirement for admission to and renewal of Fellowship and for the use of the designations FRCPC and FRCSC. For more information about the Maintenance of Certification Activity, and methods of tracking Continuing Professional Development (CPD) activities, please refer to the Royal College website. The Royal College of Physicians and Surgeons of Canada recognizes the Canadian Neurological Society (CNS) and the Canadian Neurosurgical Society (CNSS) accreditation status.

2011 Royal College of Physicians and Surgeons NEW MOC Framework Accredited Group Learning includes conferences, rounds, journal clubs, or small group activities that adhere to educational and ethical accreditation as defined by the Royal College. Accredited group learning activities can occur face to face or web-based (online). To qualify for Section 1 MOC Credits:  The Activity needs to be developed or co-developed by a physician organization.

 The Chair of the planning committee is to be selected by the CNSF.

 The planning committee must be reflective of the target audience.

 Learning activities are created based on needs as identified on CPD surveys of the target audience.

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 6/30 updated October, 2015 STEP III  Needs assessments from past CNSF CPD Events, related to a specific topic (e.g. Epilepsy), must be utilized by the planning committee.

 Planning process is to be in the control of the profession to ensure no undue influence of commercial interests and to ensure that content meets the highest standards of academic integrity and balance.

 The planning committee is responsible for identifying topic, audience, learning format, learning level, learning objectives, and CanMED roles.

 The CNSF Secretariat will be responsible for providing past CNSF Congress Needs Assessments and CPD Evaluations, templates for disclosure forms and statements, templates for Course Notes, evaluation forms.

 Learning objectives are provided from the learners’ perspective.

 The Activity integrates didactic and interactive learning strategies.

 The Activity utilizes 25% interactive learning.

 Content presented is evidence-informed and meets the highest standards of academic integrity.

 The Planning Committee, representing the target audience, is to ensure the scientific content within the Course Notes and the presentation is not biased and is evidence-based.

 Courses Notes are to be approved by the CNSF to ensure there is no undue influence of commercial interests including, but not limited to: placement of logos, co-developed statement, use of colors (e.g. drug colors may not be used in the promotion of an educational event), other subliminal messaging.

 We will evaluate:

o Were Learning Objectives met?

o Was content perceived as balanced and free from conflict of interest?

o Was time to reflect on learning provided?

o Was sufficient time for interaction provided?

Application Fee Application Fee is included within the initial negotiations with CNSF.

Application Deadline Application must be submitted no later than March 1, 2016. Please ensure the planning committee and your conference organizer is made aware of the CNSF co-developed process and timelines via receipt of the following documents. STEP I CNSF and Collaborating Partner agree to a Needs-Based Group Learning Activity STEP II Collaborating Partner Completes Education Event Checklist (Due December 1) STEP III Planning Committee Chair (CNS or CNSS member) Submits MOC Application (Due March 1)

Application Form for Accreditation Forward this completed application form (pages 9-29 of this document), along with the required supporting documentation and payment, to the Canadian Neurological Sciences Federation no later than March 1, 2016. Incomplete applications will not be accepted.

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 7/30 updated October, 2015 STEP III 1 Program Information

Event Title: Enter information Location of Event: Enter information w/ room # if available Event Date(s): Enter information Event Time(s): Enter information

Part A – Organization Requesting Approval of CPD Program Events submitted for approval under Section 1 must meet the requirements of the MOC application process. The application form must be completed by a member of the Physician Organization2 that developed or co-developed this event, and forwarded to an accredited provider for their review.

Please select the option that applies to your organization:

Physician Organization – Developed Education Event We are a Physician Organization that is planning this educational event alone or in conjunction with another Please list below all of the organizations developing this educational event. Canadian Neurological Society Canadian Neurosurgical Society Other (Please Specify) Please list below all of the organizations funding this educational event, but not providing input into program Insert Industry Name(s)

Chair of Planning Committee The chair3 of the planning committee must submit this application.

Date Application Submitted: Enter information I am a CNS member CNSS member and my membership ID # is . Name: Enter information Tel: Enter information

1 It is the responsibility of the planning committee to ensure that changes impacting advertising (speaker, dates, times, locations, etc) are communicated to the CNSF in writing.

2 Physician Organization: A not-for-profit group of health professionals with a formal governance structure, accountable to and serving, among others, specialist physicians through: Continuing professional development; * Provision of health care; and/or * Research. This definition includes (but is not limited to) the following groups: Faculties of Medicine, Hospital Departments or Divisions, Medical Societies, Medical Associations, Medical Academies, Health branch of the Canadian forces. This definition excludes pharmaceutical companies or their advisory groups, medical supply and surgical supply companies, communication companies, or other for profit organizations and ventures/activities. The term “non-physician organization” applies to all organizations that are not made up primarily of physicians; this may be an “education” or “communication” company, a CHE division of a pharmaceutical company or a disease-oriented national organization. To have a program co- developed by the CNS or CNSS, the planning committee must include a CNS or CNSS member and the CNS or CNSS must be recognized as a co- developer on all program materials. Programs planned by non-physician organizations must be co-developed by an accredited provider. 3 The Chair of planning committee MUST be a CNS or CNSS member.

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 8/30 updated October, 2015 STEP III E-mail: Enter information

Part 4 – Mandatory Education Requirements All education requirements in this section must be met, and required supporting documentation4 must be submitted (draft program, evaluation form/tools, budget identifying all sources of revenue), in order for the program to be approved under Section 1 of the MOC program.

CRITERIA 1: The event must be planned to address the identified needs of the target audience. Please provide an explanation or supporting documentation for each of the following questions: 1. Describe the identified target audience for this event. If applicable, please indicate if this event is also intended to include other health professionals. Neurologist – Adult Neurosurgeon, Neuroradiologist Neurologist – Child Neurophysiologist Resident Other (please specify)

2. Identify CanMeds roles to be discussed in relation to the topic: Medical Communicator Collaborator Manager Health Advocate Scholar Professional

Learn more: http://www.royalcollege.ca/portal/page/portal/rc/canmeds

3. List all members of the planning committee, including their medical specialty or health profession. In the case of the co-development of this educational event, please indicate which members are representing the physician organization. Insert names here

3. What sources of information were selected by the planning committee to develop the content of this event? Examples can include reviews of the scientific or education literature, clinical practice guidelines, and surveys or focus groups conducted by the organization planning the event.

Select all that apply: Review of the scientific or education literature Clinical practice guidelines Surveys or focus groups. Needs assessment Results of Evaluations from Past Sessions Other (please specify)

4. Optional: What gaps in knowledge, attitudes, skills or performance did the planning committee identify for this event? Examples of strategies to assess these needs can include assessment of physician performance from hospitals, provincial or national databases, self-assessment programs, chart reviews, 360 degree assessments, case scenarios, audits of practice and/or quality improvement activities.

Select all that apply: Assessment of physician performance from hospitals Provincial or national databases Self-assessment programs Chart reviews

4 To assist you during the application process, the CNSF Secretariat office has developed CPD Toolkits online at http://www.cnsfederation.org/CPD.html

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 9/30 updated October, 2015 STEP III 360-degree assessments Case scenarios Audits of practice Quality improvement activities. Review of Literature/ Journal Citation Review of random controlled trials/ cohort studies Review of Clinical Practice Guidelines Developments in scientific research and practice New media Other (please specify)

Criteria 2: Learning objectives that address identified needs must be created for the overall event and individual sessions. The learning objectives must be printed on the program brochure and/or handout materials. Please include learning objectives, listed below, in Schedule F. Please respond to the following questions: 1. Congress Learning Objectives The overall 2016 CNSF Learning Objectives? As a result of attending this Congress, delegates will: 1. Discuss advances in the management of acute and chronic neurological and neurosurgical disorders. 2. Discuss new findings in neurological and neurosurgical disorders. 3. Describe advances in neurological care and/or neurosurgical techniques. 4. Identify areas where there are gaps in learning (unperceived needs) not realized before attending the Congress and extend this professional learning after the Congress to the enhanced care of patients. Specific Sessions Learning Objectives As a result of attending this event, participants will: o Objective 1 o Objective 2 o Objective 3 o Objective 4

2. How were the identified needs of the target audience utilized in the creation/development of the learning objectives?

Select all that apply: Past CNSF Congress evaluations on topic from past CNSF Congress evaluations (please specify) Secondary survey or focus group based (please specify) Other (please specify)

3. Do the learning objectives express what the participants will be able to know or achieve by participating in the event? Yes No

4. How are the learning objectives linked to the evaluation strategies for this event? For example, does the evaluation form list the learning objectives or pose questions to participants about whether the learning objectives were met?

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 10/30 updated October, 2015 STEP III We will utilize the following strategies to evaluate if learning objectives were meet within individual sessions (select all the will apply): Select all that apply: Encouraging participants to complete the Evaluation form. Highlight learning objectives at beginning and end of symposium, and encourage participants to reflect on what was learned. Providing a case study, exemplifying learning objectives, before and after session. Giving an informal Q&A exercise or quiz at the end of the session. Using clicker/touch pad audience response system during session. Other (please specify)

Criteria 3: At least 25% of the total education time must be devoted to interactive learning. Please include the proposed event schedule, with times indicating discussion periods, workshops, and small group sessions, etc., with an explanation and supporting documentation for the following question:

Complete Schedule A – Agenda with time for interaction

1. What learning methods have been incorporated to promote interactive learning? Case studies Forum/panels Group/ peer exchange/ user groups Lecture/plenary method Q & A Role playing. Workshop / Hands-on demonstration Other (please specify) Discussion

Criteria 4: The event must include an evaluation of the event’s established learning objectives and the learning outcomes identified by participants. The evaluation strategies for events approved under Section 1 must include an assessment of the achievement of the identified learning objectives and provide opportunities for participants to identify what they have learned and its potential impact for their practice.

The CNSF will provide, collect, analyze and share results of the Evaluation Form.

Review Schedule B – Evaluation

1. Do you provide an opportunity for participants to identify if the stated learning objectives were achieved? Yes No

2. Are there opportunities for participants to identify and/or reflect on what they have learned? One example of this would be a question asking what the participants learned or plan to integrate into their practice).

Yes No Optional (3, 4 and 5):

3. Does the evaluation strategy intend to measure improved participant performance? Yes No If yes, please describe the tools or strategies used.

4. Does the evaluation strategy intend to measure improved health care outcomes? Yes No If yes, please describe the tools or strategies used.

5. Will the participants receive feedback related to their learning? Yes No If yes, please describe the tools or strategies used.

Part C: Meeting Ethical Standards for Continuing Professional Development Group CPD events approved under Section 1 must meet the CMA Guidelines governing the relationship between physicians and the pharmaceutical industry (Guidelines for Physicians in Interactions with Industry). The Code of Ethics for parties involved in Continuing Medical Education of the Conseil québécois de développement professionnel continu des médecins must be met in the province of Québec; and the CPD event or program evaluation form must include the following question: “Did the activity comply with the Code of Ethics for parties involved in Continuing Medical Education?” For more information on these standards, please visit the following websites:

CMA: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD08-01.pdf Quebec: http://www.cemcq.qc.ca/en/documents/guide_ethique.pdf

Each of the following ethical standards MUST be met for this event to be approved under Section 1:

1. The physician organization(s) must have control over the topics, content and speakers selected for this event. We comply with this standard: Yes No

Describe the process by which the topics, content and speakers were selected for this event.

2. The physician organization(s) must assume responsibility for ensuring the scientific validity and objectivity of the content of this event. We comply with this standard: Yes No Describe the process to ensure validity and objectivity of the content for this event.

3. The physician organization(s) must disclose to participants all financial affiliations of faculty, moderators or members of the planning committee (within the past two years) with any commercial organization(s), regardless of its connection to the topics discussed or mentioned during this event. We comply with this standard: Yes No

Complete Schedule C – Chair and Speaker Checklist

Describe how conflict of interest information is collected and disclosed to participants. For your convenience the CNSF has provided samples of disclosure forms and disclosure statements within our website http://cnsfederation.org/cpd/toolkit

4. All funds received in support of this event must be provided in the form of an educational grant payable to the physician organization(s). We comply with this standard: Yes No The CNSF receives all funds related to the co-developed symposium from our Collaborating Partners.

Provide a copy of the budget that identifies each source of revenue and expenditure for this event. In addition, please describe how the physician organization(s) assumes responsibility for the distribution of these funds, including the payment of honoraria to faculty. The CNSF collects payments from our industry partners with an additional honoraria cheque attributing honoraria to chairs, speakers, moderators. Other expenses are paid for in agreements between the CNSF and Industry partners as per the budget created by Planning Committee and attached with MOC Application.

Complete Schedule D – Symposia Honoraria Distribution Complete Schedule E – Symposia Budget

5. No drug or product advertisements may appear on, or with, any of the written materials (preliminary or final programs, brochures, or advanced notifications) for this event. We comply with this standard: Yes No Provide a copy of the preliminary program, brochure, or advanced notifications for this event.

Complete Schedule F - Template for CNSF INTERNAL Advertising

6. Generic names should be used rather than trade names on all presentations and written materials. We comply with this standard: Yes No Describe the process to advocate speakers’ adherence to using generic rather than trade names of medications and/or devices included within all presentations or written materials. Please identify all organizations that are providing funding for this event. If necessary, please use an additional page. Industry: Please provide details and names on all funding that has not been addressed above. NA. Funding related to this co-developed symposium has been identified. Other funding related to the greater CNSF Congress is disclosed within the CNSF Congress MOC Application sent for Review on April 1, 2015

Check-list: Supporting Documentation to be sent in with this application form

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 13/30 updated October, 2015 STEP III Needs Assessment Results Utilized Yes No Schedules to be Completed Schedule A – Agenda with Time for Interaction Yes No Schedule B – Evaluation Yes No Schedule C – Chair and Speaker Checklist Yes No Schedule D – Symposia Honoraria Distribution Yes No Schedule E – Symposia Budget Yes No Schedule F - Template for Internal CNSF Advertising Yes No Schedules to be Reviewed Schedule G – Course Notes Template and Yes No Materials & Advertising for Approval Schedule H – Sample of Sign-In Sheet Yes No Schedule I – Other Considerations Yes No Schedule J – Roles and Responsibilities Yes No Schedule K – CNSF Member CPD Request Yes No Schedule L – Logistical Activities Yes No

Declaration As the chair of the planning committee (or equivalent), I accept responsibility for the accuracy of the information provided in response to the questions listed on this application, and to the best of my knowledge, I certify that the CMA’s guidelines, entitled, CMA Policy: Guidelines for Physicians in Interactions with Industry (2007), have been met in preparing for this event. If this event is held in Québec, we are aware that it is mandatory to adhere to the Conseil québécois de développement professionnel continu des médecins Code of Ethics entitled, Code of Ethics for parties involved in Continuing Medical Education.

Signature (physician’s name) ______Note: Applicants should keep a list of attendees for a period of 5 years.

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 14/30 updated October, 2015 STEP III This MOC Application is due by March 1st

Complete Schedule A – Agenda with Time for Interaction The agenda may be included as a Separate Schedule or with Schedule F - Template for Internal CNSF Advertising.

Complete Schedule B – Evaluation In 2016, the CNSF will be providing you with a QR Code and a web link to be included with your materials. The QR Code will link to an online evaluation for your Symposia. Questions to be asked will include. (Subject to Change) SA = Strongly Agree A = Agree D = Disagree SD = Strongly Disagree COURSE SA A D SD The course achieved its stated learning objectives 1 Content was perceived as BALANCED and free from conflict of 2 interest or bias or outside influence Time was provided to REFLECT on learning 3 Sufficient time for INTERACTION was provided 4 I was satisfied with this course in meeting MY LEARNING NEEDS 5 I was satisfied with the RELEVANCE of this course in supporting 6 the effective care of patients Comments/ Suggestions 7

REFLECTION SA A D SD I increased my knowledge on this topic 8 I learned strategies/ skills to enhance the care of my patients 9 I had time to reflect on my attitudes and beliefs about the topic 10 I plan to apply the information learned into my practice 11 The purpose of medical CPD is to enhance the care of patients. A key change that I will make in my practice as a result of today’s session is: 12

What other continuing professional development support I require to further my learning on this topics 13

OVERALL IMPRESSION SA A D SD I was satisfied with this course in meeting MY LEARNING NEEDS 14 15 I was satisfied with the RELEVANCE of this course in supporting the effective care of patients Comments/ Suggestions

Schedule C – Chair and Speaker Checklist Maximum Chair/ Speaker Combination: 1. 1-2 hour sessions (2 people) – 1 Chair and 1 Speaker 2. 3-4 hour sessions (3 people) – 1 Chair and 2 Speakers 3. 5-8 hour sessions (5 people) – 1 Chair and 4 speakers

Speaker Providing First & Last Permission to Email Phone Course Notes Disclosure Statement Name Record by May 1, 2016 YES I have nothing to disclose YES Permission to or OR Record NO I have received the NO Permission to following: insert funds, Record grants, patents, companies See email affiliated with correspondence NA - no recording YES I have nothing to disclose YES Permission to or OR Record NO I have received the NO Permission to following: insert funds, Record grants, patents, companies See email affiliated with correspondence NA - no recording YES I have nothing to disclose YES Permission to or OR Record NO I have received the NO Permission to following: insert funds, Record grants, patents, companies See email affiliated with correspondence NA - no recording

NOTES to CNSF

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 17/30 updated October, 2015 5 Schedule D – Symposia Honoraria Distribution

Amount of Cheque Made Payable Honoraria Name of Person (Role) Mailing Address To CNSF Pays Funds in Canadian $ Only

First Name, Last Name First Name, Last Name XYZ Street $2,500 (Speaker) Calgary, Alberta T1X 1N2

5 Honoraria above were agreed upon by the Planning Committee. A cheque made payable to the Canadian Neurological Sciences Federation to cover the cost of honoraria specified in your budget. Upon MOC Application being approved, please mail the cheque to the MOC program c/o the CNSF, Suite 709, 7015 Macleod Trail SW, Calgary AB T2H 2K6. This cheque is required by the 2nd Friday in May. If your organization is unable to send a cheque by this date, the CNSF will mail cheques to individuals, upon receipt of cheque, after the Congress. Please ensure that complete mailing addresses are provided. CNSF will provide a US Bank Draft to US Speakers, provided that the appropriate exchange rate is provided by the second Friday in May. Bank Drafts will be provided at the Congress to speakers. Conference Organizer will pay travel and expenses directly to Faculty and Committee as outlined within Schedule C. The customary honorarium, to be detailed in your budget in Schedule E, is $2,500 for Chairs and Speakers.

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 18/30 updated October, 2015 Schedule E – Symposia Budget Speakers Honorarium Registration Fee Travel Handouts e.g. PowerPoint Hard Copy Total Speakers

Logistics Catering Venue Audio-Visual Other Total Logistics

Advertising Design, Printing, Mail Other Total Advertising

Other Expenses Other Other Total Other Expenses

Total Budget

NOTES to CNSF:

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 19/30 updated October, 2015 Schedule F – Template for CNSF Advertising At the time of MOC Submission, at a minimum, please include the following information as part of your MOC Application, under advertising Canadian Neurological Sciences Federation and Insert Industry Name Here present Insert Co-Developed Title Here Day, Month Date, Year (start time – end time), Room Number

Chair: First Name Last Name, CNS or CNSS Member

Course Description: NA

Faculty: First Name Last Name, CNS or CNSS Member Insert University or Hospital Title e.g. Neurologist

Learning Objectives As a result of attending the symposium, attendees will be able to: 1. Insert 2. Insert 3. Insert

Learner Level: Select all that apply Basic, Intermediate, Advanced

Target Audience: Note: Copy and paste from page 6

Learning Formats Note: Copy and paste from page 8

CanMEDs Roles Incorporated: (Please select all that apply) Medical Expert, Communicator, Collaborator, Manager, Health Advocate, Scholar, Professional For your convenience the CNSF has provided information about these roles within our website http://cnsfederation.org/cpd/toolkit

Agenda Note: Copy and paste from Schedule A

Accreditation Statement Prior to Acceptance -This is a co-developed event between the Canadian Neurological Society / Canadian NeuroSurgical Society and Insert Industry Name. This course is being reviewed for Section1 MOC credit.

Accreditation Statement Upon Acceptance -To be sent when Royal College finalizes new statement.

Symposia Recording6 This Symposia is being recorded for posting on the CNSF website. By participating in this event you are consenting to being recorded image/ audio and to any use, in any media, throughout the universe in perpetuity, of your appearance, voice and name for any purpose whatsoever. If you do not wish to be recorded, please inform the onsite staff, in the designated room, before the event begins, to let them know that you do not wish to be filmed. Thank you for your cooperation.

6 If your session is being recorded, please use this statement in advertising, and post to room door for participants to read.

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 20/30 updated October, 2015 Schedule G – Materials and Advertising for Approval Advertising Invitation Yes No NA Poster Yes No NA Exterior Room Signage Yes No NA Interior Room Banner Yes No NA Podium Signage Yes No NA Journal Advertising (Event Specific) Yes No NA

Materials Sign-in Sheet (Schedule H) Yes No NA Portfolios with Materials Yes No NA Course Notes Template for Online Course Notes Yes No NA PowerPoint Template Yes No NA Materials for Distribution Yes No NA If PowerPoint do all handouts match full PowerPoint presentation Yes No NA Evaluation Form Yes No NA

Other Tent Card Yes No NA Name Tags (not required, as Congress Delegates receive name tags) Yes No NA Props (e.g. Mirror) Yes No NA Other (please specify) Yes No NA

NOTE: Please ensure the CNSF is sent the final copy of all materials and advertising used at the Congress no later than 2nd Friday in April

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 21/30 updated October, 2015 Schedule H – Sample of Sign-In Sheet Content NOTE: CNSF will provide Sign-in sheets for use at Congress. The below is a sample, for your reference.

First Name Last Name Organization Signature

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 22/30 updated October, 2015 Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 23/30 updated October, 2015 Schedule I – Other Considerations

Video/ Audio Recording of Symposium If Industry is interested in recording a Co-developed session, for their own use and for inclusion within the CNSF medlearn.ca website, under Video, agreements must be in place prior December 1st as logistical, faculty and participant considerations must be taken into account during the planning stage. Contact Dan Morin at [email protected] or at 403-229-9544 Upon the CNSF agreeing to the recording of a Co-developed Symposium, all advertising must inform participants that recording will occur. Verbiage to be used in advertising and posted outside of the designated room:

This Symposium is being recorded for posting on the CNSF website, and for use by the sponsor. By participating in this event you are consenting to being recorded image/ audio and to any use, in any media, throughout the universe in perpetuity, of your appearance, voice and name for any purpose whatsoever. If you do not wish to be recorded, please inform the onsite staff, in the designated room before the event begins to let them know that you do not wish to be filmed. Thank you for your cooperation.

CNSF Video, Audio and Photo Policy of Congress Events for Co-Developed Symposia

Purpose The Canadian Neurological Sciences Federation (CNSF) on behalf of its four Societies7 recognizes the value of audio and/or video records of selected learning activities within the CNSF Annual Congress. The purpose is to extend accredited and unaccredited learning activities for Canadian Neurologists and Neurosurgeons to assist in their continuing professional development.

Creation of an audio/video record is secondary to the purpose of the learning activity being recorded. The fact and process of recording should be planned so there is minimal impact on the nature of the conference or event.

If a verbatim recording is being made (for whatever purpose), that fact must be known to all involved, and permission must be obtained in advance. The CNSF must receive copies of permissions and release forms, in addition to verbiage used to inform Congress delegates that the learning activity will be recorded and for what purposes it will be used.

Personal rights to privacy must be maintained, and conversational spontaneity should be preserved to the largest extent possible.

Policy Conditions Any recording of a learning activity within the CNSF Annual Congress is subject to the following conditions:  The CNSF Secretariat Office must be provided with a detailed record of how the audio or video (audio/video) will be used by December 1st of the year preceding the Congress.  All audio or video records of sessions within the CNSF Congress are made at the discretion of the Planning Committee Chair(s) and the CNSF Professional Development Committee (PDC) Representative.  Speakers, Moderators, Chairs, and others speaking or assisting in the presentation, and being recorded, must agree to be video-taped and sign a release to be provided to the Professional Development Coordinator  Recognition of the CNSF Annual Congress and the name of the co-developed session must be recognized at the beginning of recording and within all advertising and materials. Verbiage to be discussed and agreed upon.  All Congress delegates participating in the session must be made aware: o Of the type of recording to occur (video, audio, other) o Of how the recording will be used o That click through access to the learning activity can be through the CNSF website(s).  The CNSF Secretariat Office is to approve all advertising and signage related to the recording of Co-developed events related to other learning activities created through the use of recordings.

7 Canadian Neurological Society (CNS), Canadian Association of Child Neurology (CACN), Canadian Neurosurgical Society (CNSS), Canadian Society of Clinical Neurophysiologists (CSCN).

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 24/30 updated October, 2015  The learning activity created, using recordings from a session at the CNSF Annual Congress, for web-based learning: o Is not by association accredited, but the Co-developer may reapply for Accreditation separate from the Symposium MOC Application submitted to the CNSF for the Annual Congress. o The CNSF is to be offered first-right of refusal to accredit all learning activities utilizing the recordings from the CNSF Annual Congress. o Must be hosted within a secure password protected website, for the purposes of Canadian physician and surgeon learning only. o Must be available at no charge to Canadian physicians and surgeons.  Video/audio taping procedures for the session: o All equipment must be in place and set up prior to the start of any symposium. o Video company must work directly and collaboratively with the official CNSF Audio Visual Contractor. o All video or audio equipment must be stationary during any meeting and is not to be moved for any reason that can cause distraction or obstruction during proceedings. o Equipment must be set up as not to impede any exits or entrances. o Equipment must be set up in the designated areas as identified by the official CNSF Audio Visual Contractor, and CNSF representative. o The CNSF reserve the right to address any concerns regarding video/audio recording that are disruptive or otherwise causing a distraction.  When the learning activity is distributed, provision of the following information to the CNSF must occur. o Learning Activity name o Target Audience (categories to be provided by CNSF) o Accreditation Status . Section Accreditation . Accredited Provider . Number of hours of MOC credit . Accreditation Period Start (MM/DD/YY) and End (MM/DD/YY) o Learning Objectives o Write up about learning activity 500 character maximum (words, spaces, punctuation) o Other as identified by CNSF

Administration Maintenance and administration of this policy is the responsibility of the CNSF Privacy Officer.

Recording Usage The term of availability for the media is one (1) year from the time or longer, as agreed, that it is distributed and is to be used exclusively for the learning activity as agreed to by the respective parties.

Chair, Moderator, Speaker, Panelist Release Any individual who will be speaking as part of the Co-Developed Industry Symposium, and who will be recorded (video/audio), must sign a Release. Releases must be provided to the CNSF Secretariat Office prior to final approval for the recording to occur.

Audience Release Congress delegates must be notified verbally, at the beginning of the learning activity, and in writing (write-ups, signage, slides, etc.) that the session is being recorded (video/ audio). Delegates in the audience who choose to participate give their implicit permission. No releases are required.

Accommodations are to be provided for delegates wishing to ask questions, but not wanting to be recorded. This may take the form of providing an opportunity for questions to be provided by the delegate and collected by the Chair or Moderator.

Unauthorized Recording

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 25/30 updated October, 2015 Private recording is not allowed without permission. The Planning Committee Chair and the CNSF PDC Representative (or other CNSF designate) are authorized to request that the recording be stopped.

Transcription Publication Publication of any record requires the approval of all participants whose material is represented in the record.

Logistical Details Questions of archives, formats, retrieval procedures, expenses for distribution, etc. are beyond the scope of this policy. The CNSF is authorized to establish ad hoc procedures which may eventually be incorporated in a revised policy and administrative procedure.

Copyright and Permissions The scientific materials presented at the Congress are considered to be owned by the individual presenting materials, and not the CNSF. In this regard, it is the responsibility of the speaker, and by default, the organization creating additional learning activities from Co-developed symposium recordings, to ensure that a letter of copyright permission from the publisher accompanies copies of previously published material.

Video Editing The media must not be edited in such a way as to create bias or to present information in any other way than was originally included in the Symposium. CNSF Professional Development Committee approval of the media is required.

Financial Considerations Financial considerations to the CNSF may apply.

Schedule J – Roles and Responsibilities

Planning Committee Planning Committee member may include  Chair, must be a member in good standing of the CNSF (CNS or CNSS representative)  CNSF PDC Representative, not an official member of the planning committee. Contact will be Dan Morin, CEO, to assist with questions related to Royal College Standards.  Target Audience, represented on the planning committee.

Representative of Collaborating Partner and/ or Communications Representative may NOT sit on the planning committee.

The CNS or CNSS, via the planning committee, is responsible for:  Setting budget  Selecting faculty.  Ensuring appropriate learning objectives are expressed.  Informing faculty of their obligations to develop presentations which are balanced and evidence informed.  Collecting disclosure forms from ALL faculty and planning committee members to disclose ALL financial relationships over the previous 2 years.  Ensure unapproved use of products and services are declared by faculty presenters.  Where appropriate, conduct content reviews of presentations where the likelihood of commercial bias is assessed to be high.

The Accredited Provider (CNS/CNSS)  Must be represented on the planning committee and participate in the assessment of needs, activity design, implementation and evaluation, from the beginning of the process.  An accountable representative of CNSF must be on the planning committee from start of planning process. This person, assigned by the CNSF Professional Development Committee, is referred to as the CNSF PDC Representative.

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 26/30 updated October, 2015 . Participates in co-developed planning committee, as a MOC resource, from inception to completion to ensure that information required in MOC Application is completed correctly. . Upon the Accreditation Application being approved, ensure that all information indicated within the Accreditation Application is adhered to.

Secretariat Office  Coordinates Faculty and Chair honoraria.  Acknowledges financial support provided by companies within the conference materials.

Collaborating Partner  Determines and invites planning committee chair.  Provides reasonable Faculty and Chair travel expenses.  Provides the Secretariat office with flow through cheque (and accompanying disbursement documentation) for all Faculty and Chair honoraria payments.  Coordinates in the logistical planning (e.g. venue, audio-visual, catering) of the activity.

Schedule K – What CNSF Members Want from CPD Activities

Access to relevant learning activities.  Create a current, evidence-based, learning activity to maintain, develop or increase knowledge, skills, competency of physicians/ surgeons on the advances of a disease within a specialty/ subspecialty.  Course Chairs are asked to use a minimum of 2 speakers, in addition to the moderator.

Course Notes  Delegates expect Course Notes to be included within the electronic notes package provided before the Congress.  Delegates have expressed non-inclusion of materials detracts significantly from their learning experience.

Effective Use of PowerPoint Slides. We encourage the Planning Committee to provide their Power Point presentation no later than May 1stfor inclusion within the 2016 Congress Online Course Notes. Recognizing that speakers are busy if a Power Point presentation is not possible to submit for May 1st, we can provide an alternative Word template which may be submitted in lieu of the PowerPoint. Please email [email protected] and the template will be provided.

Industry is encouraged to provide PowerPoint Presentations onsite as either: (1) hard copy handouts, (2) on a CD or USB drive. See our CPD Toolkit for effective Power Point presentation hints.

Interaction between delegates and presenters.  Course design should include a combination of didactic and interactive learning strategies. Suggested interactive formats include, but are not limited to: o Pre and post case discussion representing the learning objectives. E.G. Case Study Review. o Meet the Professor – Clinical/ Case Based Session Discussions o Q & A with a Panel of Lecturers  Interaction should be a minimum of 25% of course time.

No perception of bias or self-promotion of a product, company or individual.  CNSF will acknowledge sponsors and partners within a transparent environment so that physicians are aware of the potential for bias.  Speakers, Chairs, Moderators verbally disclose and use a disclosure statement on 3rd slide for transparency.  Planning Committee creates a balanced and unbiased representation of the benefits, risks, appropriateness of all related products related to patient care.

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 27/30 updated October, 2015 Pre and Post Review of Learning Objectives.  Strategies to evaluate whether or not session learning objectives were met may be viewed within the CNSF Auditor Evaluation.

Presenters need to be Aware of Time Allotted to Speaking at Course. Delegates report that rushed presentations, due to poor planning, take away from their learning experience.

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 28/30 updated October, 2015 Schedule L – Logistical Activities

Industry is asked to work directly with CNSF Service Providers to ensure that the following logistical activities are in line with the Annual Congress processes. Additional costs may be associated with these services. These services are to be negotiated directly with the CNSF Service Providers: Venue, AV, Conference Management, Shipping.

Contact information for CNSF Service Providers will be provided by the CNSF Corporate Development coordinator, upon Co- developed Symposium agreement (part of the Sponsorship Agreement) being signed before December 1, 20XX.

CNSF Use Only

This section is to be completed by the Accredited CPD Provider and returned to the program planner. The Accredited CPD Provider should keep a copy of the completed application form.

This application is:

Approved Not approved Requires revisions prior to approval Revision approved

Name of assessor:

On behalf of (name of Accredited CPD Provider): Canadian Neurological Society Canadian Neurosurgical Society

Date of review:

Accredited CPD Provider: When the final decision regarding approval/non-approval is made, please complete Part B of the following page (notification of a group learning activity). Upon completion of the notification form, please fax (613-730-2410) or e-mail cpd- [email protected]) the form to the Royal College. If approved, the event will be posted on the Royal College web site.

Section 1 approval will be recognized by the following statement on event materials: “This event is an Accredited Group Learning Activity (Section 1) as defined by the Maintenance of Certification program of The Royal College of Physicians and Surgeons of Canada, and approved by [Accredited CPD Provider’s name] and qualifies for #.# MOC hours at 1 credit per hour. << this may be changing

Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 29/30 updated October, 2015 Application Form for MOC Section 1 Accredited Group Learning Activities CNSF Congress Co-Developed Symposium 30/30 updated October, 2015