Office of Continuing Medical Education
APPLICATION FOR SPONSORSHIP

[OPTIONAL] Form Login Account

New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish the form. The account you establish is only for this form.

NOTE: Please keep your user id and password. If you misplace it, it cannot be retrieved and you will have to create a new user id and password and your previous responses will be lost.

Applications received 60 days or less before the activity will be assessed a late fee.

Applications received 30 days or less before the activity date, will not be reviewed.

Title of Activity *

Date of Activity * +

Date of Activity +

Date(s) of Activity +

Time *

Time

Type of Activity

Check all that apply *

Course (symposium, workshop, conference, etc.)

Regularly Scheduled Series (Grand Rounds, Tumor Boards, M&M Boards, etc.)

Enduring Material

If you selected "Regularly Scheduled Series," please choose the frequency:

If you selected "Enduring Material," please choose one of the following:

Internet

Monograph

Other Other

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

MSM department

+-

Non-MSM Department and not-ACCME accredited provider Please List Company /Organization Name(s)

+-

Another ACCME accredited provider) Please List Company/Organization Name(s)

+-

CME Requested

Check all that apply (additional fees apply) *

American Medical Association Category 1 (AMA PRA Category 1)

National Commission for Health Education Credentialing (NCHEC)- Completed application must be received no less than 75 days prior to the activity start date additional information will be requested in order to apply for credit.

*American Academy of Family Physicians (AAFP) - an AAFP Member must be involved, please list AAFP member's name below

Other Other

Please list AAFP member's name

Target Audience

Check all that apply for each of the following categories:

Provider Type *

Specialty *

Location *

Indicate method(s) used to identify your target audience: *

Estimate number of attendees *

Estimate number of physicians *

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.

Name *

Title *

Organization or MSM Department *

Degrees

MD

PhD

MPH

Master of Master of

Phone

Fax

E-mail

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 of the course director.

Name *

Title *

Degrees

MD

PhD

MPH

Master of Master of

Affiliation

Department *

Address

City

State

Zip code

Phone

Fax

E-mail *

Check here if Administrative Coordinator is-NOT involved with selecting speakers, topics or influencing content

Please upload disclosure form. *

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. In addition to the Course Director and Administrative Coordinator/CME Associate.

Committee Members

	Name	Title	Degrees	Affiliation	E-mail
1	Name	Title	Degrees	Affiliation	E-mail
2	Name	Title	Degrees	Affiliation	E-mail
3	Name	Title	Degrees	Affiliation	E-mail
4	Name	Title	Degrees	Affiliation	E-mail
5	Name	Title	Degrees	Affiliation	E-mail
6	Name	Title	Degrees	Affiliation	E-mail
7	Name	Title	Degrees	Affiliation	E-mail
8	Name	Title	Degrees	Affiliation	E-mail
9	Name	Title	Degrees	Affiliation	E-mail
10	Name	Title	Degrees	Affiliation	E-mail
11	Name	Title	Degrees	Affiliation	E-mail
12	Name	Title	Degrees	Affiliation	E-mail

Please upload disclosure form. Please scan the forms into one complete file and then upload it into the application.

Planning Process Course Director

1.Who identified the speakers and topics:

Director

Activity Co-Director

CME Associate

Other (provide names) Other (provide names)

2.What criteria was used in the selection of speakers (select all that apply)?

Subject matter expert	Excellent teaching skills/effective communicator
Experienced in CME	Other Other

3.Were any employees of a pharmaceutical company and/or medical device manufacturer involved with the identification of speakers and/or topics?

No	Yes, please explain Yes, please explain

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.

Needs Assessment Data and Sources (select 2 at minimum)

A. Upload Needs Assessment documents *

B. Upload Needs Assessment documents

C. Upload Needs Assessment documents

D. Upload Needs Assessment documents

E. Upload Needs Assessment documents

F. Upload Needs Assessment documents

Planning Documents and Objectives

PROFESSIONAL PRACTICE GAP
State the problem or issue that affects the physcians' ability to perform.

0/100 words

Specify the area in which the gap is present.

	Gap Need (Check all that apply)
	KNOWLEDGE	COMPETENCE	PERFORMANCE	PATIENT OUTCOMES
LEARNING OBJECTIVE 1	KNOWLEDGE	COMPETENCE	PERFORMANCE	PATIENT OUTCOMES
LEARNING OBJECTIVE 2	KNOWLEDGE	COMPETENCE	PERFORMANCE	PATIENT OUTCOMES
LEARNING OBJECTIVE 3	KNOWLEDGE	COMPETENCE	PERFORMANCE	PATIENT OUTCOMES
LEARNING OBJECTIVE 4	KNOWLEDGE	COMPETENCE	PERFORMANCE	PATIENT OUTCOMES
LEARNING OBJECTIVE 5	KNOWLEDGE	COMPETENCE	PERFORMANCE	PATIENT OUTCOMES

IDENTIFIED EDUCATIONAL NEED
Provide the educational need that this activity will be designed to address. *

LEARNING OBJECTIVE-List the learning objectives for the activity’s learners. Each learning objective should be a specific improvement in competence, performance, or patient outcomes that this course is designed to achieve.
At the completion of this activity, participants should be able to:

PROFESSIONAL PRACTICE GAP-State the problem or issue that affects the physcians' ability to perform.

IDENTIFIED EDUCATIONAL NEED-Provide the educational need that this activity will be designed to address.

	LEARNING OBJECTIVE	PROFESSIONAL PRACTICE GAP	IDENTIFIED EDUCATIONAL NEED
1.	LEARNING OBJECTIVE	PROFESSIONAL PRACTICE GAP	IDENTIFIED EDUCATIONAL NEED
2.	LEARNING OBJECTIVE	PROFESSIONAL PRACTICE GAP	IDENTIFIED EDUCATIONAL NEED
3.	LEARNING OBJECTIVE	PROFESSIONAL PRACTICE GAP	IDENTIFIED EDUCATIONAL NEED
4.	LEARNING OBJECTIVE	PROFESSIONAL PRACTICE GAP	IDENTIFIED EDUCATIONAL NEED
5.	LEARNING OBJECTIVE	PROFESSIONAL PRACTICE GAP	IDENTIFIED EDUCATIONAL NEED

LEARNING OBJECTIVE
List the learning objectives for the activity’s learners. Each learning objective should be a specific improvement in competence, performance, or patient outcomes that this course is designed to achieve.

At the completion of this activity, participants should be able to: *

DESIRED RESULTS
List the desired results of this course. The desired results should reflect improvements in competence, performance, or patient outcomes promoted by your learning objectives . *

Methodology - Specify the educational format(s) that will be used to accomplish the stated objectives. (Check all that apply)

Activity Description
Please provide the description of this activity you will share with the learners. (No more than two paragraphs that address: 1. What is it about. 2. The audience. 3. How is it relevant.) *

Core Competencies

Please identify the core competencies that will be addressed. Click here for definitions of the core competencies. Check all that apply. *

Activity alignment with MSM CME mission statement

How does this activity align with the mission of MSM CME? Check all that apply. *

Design to help physicians provide quality health care services in keeping with prevailing professional standards of care.

Designed utilizing new and changing medical knowledge, skills, and attitudes.

Designed to correct outdated practice patterns.

Comply with established requirements for licensure, board certification, and/or professional society memberships.

Evaluation and Outcomes Measurement

How will you measure if changes in competence have occurred? Please check all that apply. Note: You will be asked to provide summary data for the evaluation methods selected.

Evaluation form for participants (completed by EPE)

Audience response system (ARS)

Customized pre and post-test

Physician and/or patient surveys

Other, specify: Other, specify:

How will you measure if changes in performance have occurred? Please check all that apply. Note: You will be asked to provide summary data for the evaluation methods selected.

Adherence to guidelines

Case-based studies

Customized follow-up survey/interview/focus group about actual change in practice at specified intervals

Chart audits

Direct observations

Other, specify: Other, specify:

How will you measure if changes in patient outcomes have occurred? Please check all that apply. Note: You will be asked to provide summary data for the evaluation methods selected.

Observe changes in health status measures

Observe changes in quality/cost of care

Measure mortality and morbidity rates

Obtain patient feedback and surveys

Other, specify: Other, specify:

This activity measures: *

Competence

Performance

Patient Outcomes

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.

What other educational strategies will you include in order to enhance your learners’ change as an adjunct to this activity?

Building Bridges with Other Stakeholders

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

Are there other initiatives within MSM working on this issue?

No	Yes, identify who: Yes, identify who:

If yes, could they be included in the development and/or execution of this activity?

No	Yes, in what ways? Yes, in what ways?

Are there external stakeholders working on this issue?

No	Yes, identify who: Yes, identify who:

If yes, could they be included in the development and/or execution of this activity?

No	Yes, in what ways? Yes, in what ways?

Identified Barriers (Select 1 at minimum) What potential barriers do you anticipate attendees may have in incorporating new knowledge, competency, and/or performance objectives into practice? Select all that apply by placing an “X” in the appropriate box. Example: If the identified barrier is cost, you would attempt to address the barrier by stating “The agenda will allow for the discussion of cost effectiveness and new billing practices”.

Lack of time to assess or counsel patients

Lack of administrative support/resources

Insurance/reimbursement issues

Patient compliance issues

Lack of consensus on professional guidelines

Cost

No perceived barriers

Other, specify: Other, specify:

Please describe how you will attempt to address these identified barriers in the educational activity.

Commercial Support

Will this activity receive commercial support? *

Please provide the information requested below:

	Company Name	Amount Requested
1	Company Name	Amount Requested
2	Company Name	Amount Requested
3	Company Name	Amount Requested
4	Company Name	Amount Requested
5	Company Name	Amount Requested
6	Company Name	Amount Requested
7	Company Name	Amount Requested
8	Company Name	Amount Requested

I have read and agree to abide by the Standards for Integrity and Independence. *

Yes

No

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

Budget Template 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.

Would you like to utilize the MSM-OEPE online registration service? *OEPE will charge the department 5% of all registration payments processed.

Yes

No

Additional assistance desired from the Office of CME

Check all that apply

Please upload the following information to complete the application process:

Program Agenda (draft acceptable) *

Budget (must include income and all expenses) *

Lecture	Group Discussion	Case Presentation
Observation	Q&A	Workshops
Panel Discussion