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Office of Continuing Medical Education
APPLICATION FOR SPONSORSHIP 

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Type of Activity

 
 

Sponsorship (Note: a pharmaceutical company or medical device manufacturer is not a sponsor)

CME Requested

 

Target Audience

Check all that apply for each of the following categories:
 
 
 

Planning and Administration

Course Director The individual responsible for the overall planning, compliance and logistics of the CME activity.  This person is usually but not limited to a physician. The Course Director, Co-Director & Contact (if applicable) and All planning committee members will be required to complete the Planning Committee Disclosure before the application will be reviewed.
 

Co-Course Director [optional] Shares responsible for the overall planning, compliance and logistics of the CME activity. This person is usually a physician but is not limited to physicians.
 

Adminstrative Coordinator/CME Associate Contact The individual responsible for the operational and administrative support of the certified activity; this is usually an administrative or staff assistant in the Department/Unit of the AMD.


 

 


PLEASE NOTE! VERY IMPORTANT

The following requested information is the most important part of this CME Application.

NO consideration can be given to this application without the following components.

1) All individuals in a position to control the content of this CME activity must disclose any relationship with a commercial interest that benefits the individual in any financial amount and 2) has occurred within the past 12 months. A conflict of interest is present when the individual has both a financial relationship with a commercial entity and has the opportunity to affect content relevant to the products/services of that commercial entity. If a conflict of interest is determined to exist, the conflict must be resolved prior to participation in this CME activity:

An individual that refuses to disclose any relevant financial relationships or with an unresolved conflict of interest must not have responsibility for, or control of, the content or planning related to the activity.

Planning Committee

NOTE: ALL individuals listed  must complete a Planning Committee Disclosure before the application will be reviewed for approval.

Please Note: You must have a minmum of two members listed below.
 NameTitleDegreesAffiliationE-mail
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Planning Process Course Director

 
 
 

Needs Assessment

The Needs Assessment should state the educational need(s) which the individual activity will address, based on the professional practice gaps for the physicians for whom the activity is designed.

Please Note: If you select more than one needs assessment, please upload a document for each needs assessment selected.

 

 

 

 

 

 

 

Planning Documents and Objectives


Core Competencies

Activity alignment with MSM CME mission statement

Evaluation and Outcomes Measurement

 
 
 

Other Educational Strategies  

Other educational strategies could be used to enhance change in your learners as an adjunct to this activity. Examples include patient surveys, patient information packets, email reminders to the learners (i.e., summary points from the lecture, new information), posters throughout the hospital, department newsletters, etc.

Building Bridges with Other Stakeholders  

 Occasionally there are other internal and/or external stakeholders working on similar issues that MSM can partner with.

 
 
 
 
 
 

Commercial Support

 Company NameAmount Requested
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Letters of Agreement for Commercial Support must be signed by the Office of CME ONLY and the commercial supporter representative.

 

Preliminary Budget   

We strongly encourage you to use the MSM OEPE budget template.  If you have your own template, please ensure that projected income and expenses are listed in detail.

 

Participant Registration

MSM-OEPE has the ability to capture registrations and associated payments via our website calendar – the data links directly to our CME database – registration reports (including financial information) and name badge templates are provided; collected registration fees are transferred to a department fund code. 

Additional assistance desired from the Office of CME

 


Please upload the following information to complete the application process:


 

 
* Indicates Response Required