ࡱ > 0 bjbj?? 4 ] ] & 2 8 , D f t A L . f f f f f f f h k d f - f S Ef S S S : f S f S S W F] ?gv8 1 " zY 6 b] [f 0 f Y l S l l F] S F] K :
7860 Peters Road, F111 Plantation, Florida 33324 (954) 723-0057 Phone (954) 723-0353 Fax HYPERLINK "http://www.naceonline.com" www.naceonline.com HYPERLINK "mailto:info@naceonline.com" info@naceonline.com
APPLICATION FOR JOINT SPONSORSHIP
OF A CONTINUING MEDICAL EDUCATION ACTIVITY
The National Association for Continuing Education (NACE) is pleased to consider your request to jointly sponsor the educational activity you are planning for continuing medical education (CME) credit. Please carefully review the Joint Sponsorship Application and completely answer all the questions before submitting it to NACE for review. This application must be submitted electronically to HYPERLINK "mailto:sgraham@naceonline.com" sgraham@naceonline.com at least 90 days prior to the educational activity. Mailed or faxed applications will not be accepted.
A checklist of all documentation to be submitted to NACE is included at the end of this application. Use this checklist to keep track of submissions and approvals from NACE.
NACE must accept responsibility for ensuring that all jointly sponsored activities are planned and implemented in accordance with the Accreditation Council for Continuing Medical Education (ACCME) Essential Areas and Policies. NACEs policy on joint sponsorship of CME activities is based on the following principles:
All jointly sponsored activities must be for scientific and educational purposes only; the educational content of jointly sponsored activities must be acceptable by the medical profession as being within the basic medical sciences, discipline of clinical medicine, and the provision of healthcare to the public.
As the accredited provider, NACE must be involved in the planning, implementation, and evaluation of any CME activity for which it chooses to enter a joint sponsorship relationship with a non-accredited entity.
NACE must review and approve the needs assessment process, activity learning objectives, design and format of the activity, final faculty selection, and methodology used to evaluate the activity.
NACE must review and approve all materials associated with the activity prior to their release.
All jointly sponsored activities must comply with the ACCME Standards for Commercial Support: Standards to Ensure the Independence of CME Activities, the FDA Final Guidance on Industry Supported Scientific and Educational Activities, and the AMA regulations regarding the Physicians Recognition Award, the AMA Opinion 8.061: Gifts to Physicians from Industry, and the AMA Opinion 9.011: Continuing Medical Education.
NACE charges an application fee for each joint sponsored activity. For information about application fees, contact NACE at (954) 723-0057. Send your completed application to: NACE, 7860 Peters Road, Suite F111, Plantation, FL 33324 or email to: HYPERLINK "mailto:sgraham@naceonline.com" sgraham@naceonline.com. Allow two weeks for final approval of applications submitted.
Cordially,
Harvey C. Parker, Ph.D.
Director of Continuing Education
APPLICATION FOR JOINT SPONSORSHIP
OF A CONTINUING MEDICAL EDUCATION ACTIVITY
APPLICANT:
Organization:
Address:
City, State, Zip:
Contact Person:
Telephone:
Fax:
Email:
Is your organization a commercial interest (any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients)?
YesNo
PROPOSED ACTIVITY TITLE:
START DATE OF PROGRAM:
SUBMISSION DATE:
PLANNING COMMITTEE MEMBERS (Include Name and Affiliation):
ACTIVITY SUBJECT MATTER:
Identify the general topic area to be discussed in the activity [i.e. cardiology, psychiatry, womens health, lifestyle, etc.].
Define the medical subject(s) to be discussed in the activity [i.e. depression, prostate cancer, hypertension, dyslipidemia, etc.].
INTENDED AUDIENCE:
Define the target audience [i.e. primary care providers, oncologists, gynecologists, etc.].
Identify lists and/or sources for audience recruitment or distribution [i.e. society mailing list, AMA list, supplemental distribution by supporters personnel, web-based advertising, etc.].
EDUCATIONAL PLANNING
List gaps in knowledge, performance or practice that will be addressed by this activity. (C2)
Identify educational need(s) of knowledge, competence, or performance, derived from the above professional practice gaps. (C2)
What method(s) were used to determine the educational gaps/needs of the target audience?
Public Health DataNational or Regional GuidelinesPrevious Activity Evaluation DataNew Developments/TechniquesSurvey of Target AudienceLiterature SearchFaculty Perception of NeedOther:
Attach a summary of your needs assessment (i.e. literature review, summary of evaluation data, etc.)
Based on the need/gap(s) identified, what are the desired results of this activity? (C3)
Change in physician competenceChange in physician performanceChange in patient outcomes
Based on the needs and desired results, list the learning objectives that will be used to direct the content of this CME activity. (C2)
At the conclusion of this CME activity, attendees will be able to:
Describe how this content matches the learners current or potential scope of professional activities. (C4)
How will this content be delivered? (C5)
Live FormatsEnduring formatsSymposiumNewsletterLecture SeriesMonographTeleconferenceDVDWebinarJournalOther:InternetAudio/VideocassetteOther:
If a live activity, list dates and locations.
What instructional formats will be used? (C5)
LecturePanel discussionSimulationCase presentationsRound tableQuestion and AnswerOther:
How does the format/design of the activity support the activity objectives and desired results? (C5)
Which desirable physician attributes does this CME activity address? (C6)
IOM ComeptenciesACGME/ABMS MOC Competenciesdelivering patient-centered carepatient careworking as part of interdisciplinary teamsmedical knowledgepracticing evidence-based medicineinterpersonal and communication skillsfocusing on quality improvementprofessionalismusing information technologysystem-based practicepractice-based learning and improvementAMA Code of EthicsOther:
How will you address these factors in the design of your CME activity (C6)?
Identify factors outside of our control as a CME provider that may have an impact on patients outcomes in this disease state. (C18)
Patient compliance and adherence to treatmentPatient understanding of physician instructionsPhysician resistance to changeReimbursement issuesInadequate access to careCost of carePhysician interpersonal communication skillsOther:
How will you address these factors in the design of your CME activity (C18)?
CME ACTIVITY EVALUATION
What method(s) will be used to evaluate if the activity was effective at meeting the need and desired results as identified above (i.e., creating change in learners competence or performance or changes in patient outcomes)? List method(s) for each type of change indicated. (C11)
CME ACTIVITY DESCRIPTION
Proposed Agenda if live meeting. (Include beginning and ending times of each lecture, title of each lecture and proposed presenter.)
Proposed content if enduring material:
Number of credits requested:
List potential faculty members and their affiliations.
Describe the process used to identify the proposed faculty.
Prior Working RelationshipNoted AuthoritiesLiterature SearchClinical InvestigatorInput from Medical/Scientific ExpertsOther:
COMMERCIAL SUPPORT
List the names of any potential commercial entities that may provide support for the activity.
NACE USE ONLY
REVIEW AND CERTIFICATION
This activity has been reviewed and approved for joint sponsorship.
____ Yes or _____ No
The National Association for Continuing Education designates this educational activity for a maximum of ___ A M A P R A C a t e g o r y I C r e d i t ( s ) "!. P h y s i c i a n s s h o u l d o n l y c l a i m c r e d i t c o m m e n s u r a t e w i t h t h e e x t e n t o f t h e i r p a r t i c i p a t i o n i n t h e a c t i v i t y .
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
N A C E S t a f f M e m b e r D a t e
C H E C K L I S T O F I T E M S T O B E S U B M I T T E D T O N A C E
Title of CME Activity:
DATE SUBMITTEDDATE APPROVEDITEMJoint sponsorship application with full needs assessment as attachment SUBMIT THE FOLLOWING ITEMS AFTER THE CME ACTIVITY HAS BEEN APPROVED AND WITHIN 14 DAYS OF THE MEETING/RELEASE DATEDisclosure Forms for the Course Director(s), planning committee members, faculty members, and anyone else involved in the planning of the CME activityConflict of Interest Resolution Forms for anyone listing financial relationships on the Disclosure FormCVs for for the Course Director(s), planning committee members, faculty members, and anyone else involved in the planning of the CME activityLetters of Agreement executed by all parties for all companies providing commercial supportDraft brochure and/or marketing materials to be approved before being releasedDraft handbook and/or meeting materials to be approved before being releasedDraft evaluation form to be approved before being released (Use NACE template)Draft outcomes study to be approved before being released (Use NACE template)SUBMIT THE FOLLOWING ITEMS WITHIN 10 DAYS
OF THE END OF THE CME ACTVITYList of attendeesSign-in and Sign-out sheet for live activitiesSpreadsheet of individuals requesting credit (Use NACE template)Final brochure/marketing materialsFinal handbook/meeting materialsCompleted evaluation formsSummary report of evaluationSummary report of outcomes studyReconciled budget
PAGE
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7/29/08 V1.0
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