Cme.nychhc.org
New York City Health and Hospitals Corporation
Division of Medical and Professional Affairs
Office of Patient Centered Care
Continuing Medical Education
Activity Application
Instructions for Completing the Application for Accreditation of CME Program Activities
The complete application package must be submitted at least six (6) weeks before the planned program activity. Please submit one (1) copy of the completed application to the Office of Patient Centered Care at 346 Broadway 11th Floor, Suite 1136or a scanned copy of the application. There will be no retrospective approval or accreditation of any program activity; no credits may be awarded to programs conducted which had not been previously approved.
Only one application for a CME or CE activity that will be given multiple times (one program repeated in various facilities on different dates), or a series of learning sessions (grand rounds, etc.) needs to be completed.
1. Form 1: Provide a general description of the proposed CME or CE activity, including the intended audience; grant and other non-corporate sources of funds including commercial interests; presence of commercial exhibits, and amenities that will be made available to attendees.
Append a draft of the program announcement and program agenda with the appropriate CME or CE accreditation statement, learning objectives, financial disclosure from faculty, and financial support from other organizations. Brochures, program announcements, and publications used to promote or distributed at the program activity must include the following statements:
1.a. CME Accreditation Statement for direct sponsorship:
New York City Health and Hospitals Corporation is accredited by The Medical Society of the State of New York to provide continuing medical education for physicians. New York City Health and Hospitals Corporation designates this (enter type of learning activity) educational activity for a maximum of (number of credits) AMA PRA Category 1 Credit(s)TM. Physicians should claim only credit commensurate with the extent of their participation in the activity.
CME Accreditation Statement for joint sponsorship:
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Medical Society of the State of New York (MSSNY) through the joint sponsorship of New York City Health and Hospitals Corporation (NYC HHC) and (Name the Non-Accredited Provider). New York City Health and Hospitals Corporation is accredited by MSSNY to provide continuing medical education for physicians. NYC HHC designates this (Type of Activity) for a maximum of (Number of Credits) AMA PRA Category 1 Credits™. Physicians should claim only credit commensurate with the extent of their participation in the activity.
1.b. Program Learning Objectives:
At the conclusion of the course, program participants are expected to:
1. (insert learning objectives)
1.c. Statement about the source of commercial funds, grants, and others, e.g.:
This activity is supported by an unrestricted educational grant from (insert source of fund).
1.d. Disclosure Statement
Policies and standards of the MSSNY, ACCME, AMA, and ADA require that faculty and planners for continuing medical education and continuing education activities disclose any relevant financial relationships they may have with commercial interests whose products, devices or services may be discussed in the content of a CME or CE activity.
The following faculty members and planners have no relevant financial relationships to disclose:
(insert names of faculty members and planners)
The following faculty members and planners asked to disclose information about their financial relationships:
(insert name of faculty members and planners along with name of commercial interest(s) and the nature of the relationship(s).
2. Form 2: Describe the educational needs (knowledge, competence, or performance) that underlie the professional practice gaps of the intended audience. Include the needs assessment data to plan CME or CE activity. Indicate participation of commercial interests in the planning process, if any.
3. Form 3: Provide the learning objectives of the proposed CME or CE program activity, and for each of the topics in the program activity. These learning objectives must also be on the formal printed CME or CE program or agenda distributed during the educational session(s). Please ensure that these learning objectives correspond to the ‘needs’ identified in needs assessment (Form 2).
4. Form 4. Provide the educational format of the proposed CME or CE program. Append an outline, brief description of the presentation, or the slides to be presented by each of the faculty. Ensure that learning objectives for the presentation(s) and the faculty disclosure of any potential conflict of interest are included in the presentation.
5. Form 4-A. Provide a list of the faculty and planning committee members. Append curriculum vitae or resume of the faculty member, program directors and planning committee members.
6. Form 4-B Provide Objectives: What the participant will learn; Content topics: What the learner will be taught; Time frames: Specified time in minutes to deliver the content; Presenters: Who will deliver the content; Teaching methods: Mode of content delivery. Objectives should be learner oriented outcomes that are expressed in measurable terms, identify observable actions and specify one action or outcome per objective. The number of objectives should be sufficient to accomplish the intended purpose of the activity
7. Form 5. Describe how the learning session will be evaluated for its effectiveness. Ensure that the evaluation of the educational sessions and any evaluation tools used by participants are submitted to the CME and CE Program office within one month after the conclusion of the educational session. In addition to the participants’ and program directors’ evaluation of the learning session, include at least one additional strategy to evaluate program effectiveness.
8. Form 5-A: Suggested model for participant’s evaluation and attendance attestation. If not using this format or if the program director wishes to separate the ‘program evaluation’ from the ‘attendance attestation’, append these forms to collect participant’s evaluation and attestation of attendance of the learning session. CME credits will only be provided to participants who complete and submit an evaluation and, or, attendance attestation form.
9. Form 5-B: The program director must complete this general evaluation of the learning session.
10. Form 6: Sample Participants Sign-in Sheet. If not using this format, append any other form that will be used to document attendance in the learning session.
11. Form 7: Budget for the proposed CME or CE activity. Provide all funding source(s) including commercial interests, and program participant fees when applicable.
12. Form 8: All members of the faculty including program moderators, program directors and members of the program planning committee must complete the conflict of interest and financial disclosure form.
Financial relationships to be disclosed include receiving salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefits. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.
Relevant financial relationships with commercial interests of any amount are those which exist in the 12-month period proceeding the time that the individual is being asked to assume a role controlling content of the CME or CE activity.
It is deemed a Conflict of Interest when an individual has an opportunity to affect CME or CE content about products or services of a commercial interest with which the individual has a financial relationship.
A satisfactory resolution of any conflict of interest must be achieved before the individual could continue to participate in anyway in the proposed CME or CE activity.
13. Form 9: Financial Disclosure for the Presenting Organization. Provide all information on external support, financial or ‘in-kind,’ for this CME or CE activity. Commercial Support must be in the form of unrestricted educational grants to the sponsoring organization to ensure independence from commercial interest and that the educational program is free of commercial bias.
ACCME defines ‘Commercial Interest’ as any proprietary entity producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies.
The ADA defines ‘Commercial Support as financial support, products, and other resources to support or offset expenses and/or needs associated with a provider’s continuing dental education activity’ and ‘Commercial Supporter as entities which contribute financial support, products, and other resources to support or offset expenses and/or needs associated with a provider’s continuing dental education activity.’
14. Form 10: Written Agreement for Commercial Support to ensure independence of educational activities from commercial bias between the organizational director offering the CME or CE activity and the commercial donor, if any. Complete one written agreement for each source of commercial support. Indicate ‘No Commercial Donor’ on this form if there is no such sponsorship.
15. Form 11: CME Program Committee Review and Approval.
FORM 1 GENERAL DESCRIPTION OF CME PROGRAM ACTIVITY
I Title: _________________________________________________________________________
II Presenting Organization: _________________________________________________________
III. Location of Educational Activity: ___________________________________________________
IV Course Director(s):
Name: ______________________________ Name: ____________________________________
Address: ____________________________ Address: __________________________________
Email: ______________________________ Email: ____________________________________
Telephone: __________________________ Telephone: ________________________________
Fax: _______________________________ Fax: _____________________________________
V. Date(s) for activity (For regularly scheduled series please include documentation of scheduled dates):
| | |
| | |
VI. Screening Criteria (Note: If none of the following apply, please reconsider the need for this educational intervention)
[ ] Content is based on evidence that constitutes ‘best practices’
[ ] Gap exists between current and best practices
[ ] Closing the gap will result in improvement in the health and, or, outcome of patients
[ ] The proposed educational intervention will result in change in practice
VII. Intended Audience:______________________________________________
A. Will this program be open to non-corporate providers? [ ] No [ ] Yes
B. Will fees be charged for participation in this program? [ ] No [ ] Yes
VIII. Number of AMA PRA Category 1 Credit(s)TM requested: ____________________________
IX Will there be commercial sponsors or external funding source for this program? [ ] Yes [ ] No
If yes, please identify funding source:
| |
| |
(Commercial support may only be accepted as unrestricted funds)
X. Promotional Activities
Will there be commercial exhibits and, or, items from commercial interest for participants in this program activity?
[ ] Yes [ ] No
(Commercial exhibits are not permitted at the entrance to, or on a direct or unavoidable path to the educational program activity, or in the same room where program activities will be provided.)
[ ] Yes [ ] No
Will there be meals served supported by commercial interests? [ ] Yes [ ] No
If yes, provide statement to disclose this matter: _____________________________________________
XI. Attach proposed/draft of Program Announcement and Program Agenda to include the following information: Must be included to complete application
A. Program Learning Objectives (minimum of three)
B. CME accreditation statement:
The New York City Health and Hospitals Corporation is accredited by the Medical Society of the State of New York to sponsor continuing medical education for physicians.
The New York City Health and Hospitals Corporation designates this educational activity for a maximum of (number of credits) AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
C. Financial disclosure and conflict of interest statement:
Participating faculty members and planners have no relevant financial relationships to disclose: (insert names of faculty members and planners)
Or
The following faculty members and planners asked to disclose information about their financial relationships:
• Insert name of faculty members and planners
• Name of commercial interest(s) and the
• Nature of the relationship(s)
D. Financial support from any organization:
This activity is supported by an unrestricted educational grant from: _________________________________
XII. Educational Activity Overview
Use Attached Educational Activity Table to Supply Items 1-5
1. Objectives:
Indicate what the participant will be able to do at the conclusion of the activity. Objectives should be written in measurable terms given the time frame and teaching method. An average of 1-2 objectives per hour is realistic.
2. Content:
Itemize key points that will be addressed with each objective. Content must be more than a restatement of the objective and must be related to the objective.
3. Time Frame:
Indicate the number of minutes for each objective for live presentations.
4. Presenter:
List the faculty who will be addressing each objective (this is not applicable for content specialists).
5. Teaching Methods:
List the methods, strategies, materials, and resources to be used by faculty to cover each objective.
FORM 2 NEEDS ASSESSMENT FOR THE CME or CE ACTIVITY
I. Why is this learning session necessary?
This learning session has been designed to meet identified gaps in knowledge and competence of providers on:
|1 |
|2 |
|3 |
|4 |
|5 |
|6 |
|7 |
|8 |
|9 |
|10 |
and/or to address the following specific performance measures:
|1 |
|2 |
|3 |
|4 |
|5 |
|6 |
|7 |
|8 |
|9 |
|10 |
II. How was the gap in knowledge, competence, or performance measure determined or identified?
(Append measurement tools, if appropriate)
| |
| |
| |
| |
| |
| |
| |
III. Has there been any participation by a commercial interest in the needs assessment and/or planning for this learning activity? [ ] No [ ] Yes.
If YES, please identify commercial interest: ________________________________________________________
FORM 3 LEARNING OBJECTIVES OF THE CME or CE ACTIVITY
I. State Learning Objectives for the CME or CE program activity.
Please ensure that the learning objectives are designed to meet the identified gaps in knowledge and skills, or performance measures identified in Form 2: Needs Assessment.
At the conclusion of the course, the participants should be able to:
1. ______________________________________________________________
2. ______________________________________________________________
3. ______________________________________________________________
4. ______________________________________________________________
5. ______________________________________________________________
II. Append the specific learning objectives for each topic or presentation in the CME or CE learning session.
1. ______________________________________________________________
2. ______________________________________________________________
3. ______________________________________________________________
4. ______________________________________________________________
5. ______________________________________________________________
FORM 4 EDUCATIONAL METHODS TO ACHIEVE LEARNING OBJECTIVES
I. Indicate the educational methods that will be used to achieve aforementioned objectives for this CME or CE program activity.
[ ] Lecture [ ] Performance Improvement Activity
[ ] Case Presentation [ ] Committee Work
[ ] Workshop [ ] Internet-based Learning Session/Web Conference
[ ] Panel Discussion [ ] Other ________________________________
Lectures, Case Presentations, Workshops, or Panel Discussions:
Append an outline of each speaker’s presentation and a copy of any slide presentation that will be used
Performance Improvement Activity: Append a description of the activity by which the participants can learn about specific performance improvement measures including: a) assessment of a particular health outcome in their practice; b) development and application of specific interventions or measures over a useful interval designed to improve health outcome; and c) evaluation of their performance through a reassessment of the particular health outcome addressed in (b).
Committee Work: Append the nature of the work of the committee, the specific item for discussion or work to be completed during the accredited session and the Learning Objective for that particular session. Invited presenters to the Committee meeting will be considered ‘faculty’ and must comply with all other requirements for faculty members.
Internet-based Learning Sessions, Enduring Materials and other participant-initiated learning activities: Append the description of the activity, process of accessing the learning modules, evaluation, and documentation of completion of learning activities, and linkage to the NYC HHC CME and CE website.
FORM 4-A LIST OF FACULTY MEMBERS AND PROGRAM PLANNING COMMITTEE
I. Provide a list of faculty members and the program planning committee, including the relationship with any commercial interests of each of the individuals in this list.
|Name & Credentials |Organizational Affiliation |Participant Status |Commercial Interest Affiliation |
| | | |(if any) |
| | |Planner |Faculty | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
II. Append the curriculum vitae and a signed disclosure form of each of the individuals in this list to this form.
FORM 4-B EDUCATIONAL ACTIVITY OVERVIEW
|OBJECTIVES |CONTENT (Topics) |TIME FRAME |PRESENTER |TEACHING METHODS |
|Learner-oriented, with at least one measurable behavioral|Outline of the content to be covered that will |Indicate the time frame for|List the faculty or content expert |Describe the teaching methods, strategies, |
|verb per objective |enable the learners to meet their objectives |each objective. |for each objective. |materials, and resources for each objective. |
| | | | | |
|The Participant will be able to: | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
FORM 5 EVALUATION OF THE EFFECTIVENESS OF THE PROGRAM ACTIVITY
I. Indicate the anticipated outcome of the learning activity:
1. [ ] enhance provider knowledge and skills;
2. [ ] change in provider practice;
3. [ ] change/improvement in health outcome; or
4. [ ] other ____________________________.
II. In addition to the evaluation conducted by participants and program directors, indicate at least one additional evaluation method to be utilized, and submit copies of evaluation tools or tests.
1. [ ]Participants’ evaluation (See Form 5-A, model ‘Participant’s Evaluation and Attendance Attestation’)
2. [ ]Program Directors’ evaluation (See Form 5-B, ‘Program Director’s Evaluation’)
3. [ ] Pre-test/ Post-test (Append to this application form)
4. [ ] Skills or Competence Assessment or Participant Interview (Append Assessment or Interview tool)
5. [ ] Peer Review (Append Peer Review tool)
6. [ ] Faculty Perception (Provide Faculty Assessment tool)
7. [ ] Health Outcome Indicators (Provide Performance Measures)
8. [ ] Other________________________________________________________________.
III. Submit to the CME and CE Program Committee, within one month of the date of the CME or CE activity the
following:
1. Completed ‘Participant’s Evaluation and Attendance Attestation’ forms (No credits or certificate of attendance will be provided to participants without completed form).
2. Completed ‘Director’s Evaluation form’
3. Copy of the Participant Sign-In or Attendance Sheet.
IV. Indicate when the results of any additional assessment for program effectiveness will be completed and submitted: ________________________________________________________
FORM 5-A PROGRAM EVALUATION AND ATTENDANCE ATTESTATION
|Title: |
|Location: |
|Date(s): |
|Rating scale: : 4=Excellent 3=Good 2=Fair 1=Poor |Excellent |Good |Fair |Poor |
|1. To what extent did the objectives relate to the overall goal & |4 |3 |2 |1 |
|purpose of this learning activity? | | | | |
|2. To what extent have you achieved the following objectives of |4 |3 |2 |1 |
|this session? | | | | |
|a) |4 |3 |2 |1 |
|b) |4 |3 |2 |1 |
|c) |4 |3 |2 |1 |
|3. Rate the effectiveness of each presenter: |4 |3 |2 |1 |
|a) |4 |3 |2 |1 |
|b) |4 |3 |2 |1 |
|c) |4 |3 |2 |1 |
|d) |4 |3 |2 |1 |
|e) |4 |3 |2 |1 |
|f) |4 |3 |2 |1 |
|4. To what extent were the teaching strategies appropriate? |4 |3 |2 |1 |
|5. To what extent did the audiovisual presentations contribute |4 |3 |2 |1 |
|to this program? (If applicable) | | | | |
|6. To what extent did the written materials contribute to this |4 |3 |2 |1 |
|program? | | | | |
|7. The location and environment was conducive to learning? | | | | |
|8. Was this program fair, balanced, and free of commercial bias? |Yes |No |If “No’, Please explain: |
| | | |___________________________________|
| | | |___ |
|Disclosure regarding Conflict of Interest(s): |
|The provider of this activity disclosed in writing or verbally the conflict of interest or lack thereof |YES | |NO | |
|declared by the planners and presenters/content specialists. | | | | |
What changes will you make in your clinical practice based on this learning session? ________________________________________________________________________________________
What other topics would you suggest for future learning sessions?
________________________________________________________________________________________
Participant’s Name: ______________________________ _
Credentials (Circle one)
|MD |OD |DDS |PA |NP |RN |LPN |
|Social worker |Psychologist |Other: |
Email: _____________________ ____________________ (Please Print Name Legibly)
FORM 5-B PROGRAM DIRECTOR’S EVALUATION
Title: ____________________________________________________________
Location: ____________________________________________________________
Date(s): ____________________________________________________________
1=Strongly Agree, 2=Agree, 3=Somewhat Agree, 4=Disagree, 5=Strongly Disagree
1. The CME learning session achieved its learning objectives: [ ]
2. The faculty is effective and achieved individual learning objectives: [ ]
3. Conflict of interest and financial relationship with commercial interests were fully disclosed: [ ]
4. The facility (including the technical and logistical arrangement) was conducive to learning: [ ]
5. Indicate when the results of other assessment for program effectiveness will be available and submitted: _____________________________________________________________
Comments: _________________________________________________________________
______________________________________ ______________________
Program Director’s Signature Date
FORM 6 Participants Sign-in Sheet
Title: ____________________________________________________________
Location: _____________________________________________________________
Date(s): _____________________________________________________________
|Name |Clinical Title |Facility |Email Address |
|Please Print |MD, DO, RN, NP, PA, MSW | |Please Print |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
Submit to CME and CE Program office no later than one month after the CME or CE Program Activity has been completed.
This is a sample sign-in sheet. You may use your own; however, each attendance sheets must have all of the above identified categories
FORM 7 BUDGET FOR THE CME PROGRAM ACTIVITY
Title: ____________________________________________________________
Location: ____________________________________________________________
Date(s): ____________________________________________________________
Program Director(s): ________________________________________________________
________________________________________________________
Estimated Expenses: (Please Itemize)
|Description |Amount |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
Estimated Income from All Sources: (Please itemize and include name of entities providing: commercial support, grants, fees, and others).
|Commercial Support |Grants |Fees |Others |
|Providing Entity |Amount |Providing Entity |Amount |Providing Entity |Amount |Providing Entity |Amount |
| | | | | | | | |
| | | | | | | | |
| | | | | | | | |
| | | | | | | | |
| | | | | | | | |
| | | | | | | | |
| | | | | | | | |
| | | | | | | | |
| | | | | | | | |
Total Income:
Total Expenses:
FORM 8 FINANCIAL DISCLOSURE FOR INDIVIDUAL FACULTY, MODERATOR, PROGRAM DIRECTOR & PLANNING COMMITTEE MEMBER
Title: ____________________________________________________________
Location: _____________________________________________________________
Date(s): _____________________________________________________________
1. Have you (or your spouse/partner) had a personal financial relationship in the last 12 months with the
manufacturer of the products or services that will be presented or discussed in this CME activity
[ ] Yes [ ] No
If No skip to DECLARATION section below. If Yes please list your disclosure and resolutions below.
|Commercial Interest |Nature of Relevant Financial Relationship |
| |Employee, Grants/Research Support recipient, Board Member, Advisor or Review Panel Member, |
| |Consultant, Independent Contractor, Stock Shareholder (excluding mutual funds), Speakers’ |
|Name of Company |Bureau, Honorarium recipient, Royalty recipient, Holder of Intellectual Property Rights, or|
| |Others (specify) |
|1. | |
|2. | |
|3. | |
|4. | |
|5. | |
2. Resolution of Conflict of Interest
Faculty
[ ] I will support my presentation and clinical recommendations with the ‘best available evidence’ from the medical literature.
[ ] I will refrain from making recommendations regarding products or services, e.g., limit presentation to pathophysiology,
diagnosis, and/or research findings.
[ ] I will recommend alternative presenter for this topic for the planning committee’s consideration.
[ ] I will submit my talk in advance to allow for adequate peer review.
[ ] I will or have divested myself of this financial relationship.
Planners/Others
[ ] To the best of my ability, I will ensure that any speakers or content of this program activity is independent of commercial bias.
[ ] I will recuse myself from planning activity content in which I have conflict of interest.
Declaration: I will uphold academic standards to ensure balance, independence, objectivity, and scientific rigor in my role in this CME activity. In addition, I agree to comply with the requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Signature: _______________________________________________________________ Date: _________________
Print Name: ______________________________________________________________________________________
FORM 9 FINANCIAL DISCLOSURES FOR THE PRESENTING ORGANIZATION
Title: ____________________________________________________________
Location: ____________________________________________________________
Date(s): ____________________________________________________________
Has external sources of funding been requested/received for this CME activity? [ ] Yes [ ] No
If Yes, Please identify
Source of External Fund or ‘In-kind’ Contribution: ________________________
Address: ________________________________________________________
Amount of Fund Requested/Received: _________________________________
Source of External Fund or ‘In-kind’ Contribution: ________________________
Address: ________________________________________________________
Amount of Fund Requested/Received: _________________________________
Source of External Fund or ‘In-kind’ Contribution: ________________________
Address: ________________________________________________________
Amount of Fund Requested/Received: _________________________________
Source of External Fund or ‘In-kind’ Contribution: ________________________
Address: ________________________________________________________
Amount of Fund Requested/Received: _________________________________
Please use additional pages if needed.
Note: If source of funds is a commercial interest(s), please complete and append Form 10: Written Agreement for Commercial Support. Complete an ‘agreement’ with each commercial sponsor.
Program Director: __________________________________________________
Signature: _______________________________ Date: ____________________
Form 10 WRITTEN AGREEMENT FOR COMMERCIAL SUPPORT
Title: ___________________________________________________________
Location: ___________________________________________________________
Date(s): ___________________________________________________________
Commercial Sponsor: _________________________________________________________
Address: _________________________________________________________
Contact Person: _______________________ Email: ______________________
Telephone No.: _______________________ Fax: ________________________
Terms, Conditions, and Purposes
1. This activity is for scientific and educational purposes only and will not promote any specific proprietary business interest of the Commercial Sponsor.
2. The Director(s) of the CME or CE activity
• Is responsible for the identification of the educational need, content of the program activity, learning objectives, selection of faculty, educational methods, and evaluation of the activity;
• Ensures the objectivity of any discussion of commercial products which occurs during the program activity, as well as disclosures, to the extent possible of limitations of data presented about the commercial product; and
• Requires faculty to disclose when a product is not approved in the US for the use under discussion;
• Will accept the full amount of the educational grant, and will make all decisions regarding the disposition and disbursement of the funds from the Commercial Sponsor.
• Will furnish the Commercial Sponsor, upon request, with the full details of the expenditure of the educational grant.
3. The Commercial Sponsor:
• Will not require HHC CME and CE Program and the Program Director(s) to accept advise or services concerning faculty, authors, or participants or other educational matters as conditions of receiving this grant;
• Will inform HHC CME and CE Program of the educational grant to support this activity; no other payments apart from the educational grant shall be made to the Program Director(s), planning committee members, teachers or authors, joint sponsors, or any others involved with this activity;
• Will not include advertising materials and editorial on the same products in any printed materials for this activity;
• Will not conduct commercial promotional activities including distribution or exhibition of product-promotional material or product-specific advertisement of any type, in the educational space immediately before, during or after the CME or CE activity;
• Will not be the agent providing the CME or CE activity to the learners.
4. Disclosure
The HHC CME and CE Program and the Program Director(s) will ensure that the source of support from the Commercial Sponsor, either direct or ‘in-kind,’ is disclosed to the participants, in program brochures, syllabi, and other program materials, and at the time of the activity. This disclosure will not include the use of trade name or a product-group message.
The acknowledgment of commercial support may state the name, mission, and clinical involvement of the company or institution and may include corporate logos and slogans, if they are not product-promotional in nature.
The director(s) and the commercial sponsor agree to abide by all requirements of the ACCME and MSSNY “Standards for Commercial Support of Continuing Medical Education,” the American Dental Association, and the New York State Education Department.
Signature HHC Director: ___________________________ Signature Commercial Sponsor: ___________________________
Print _________________________________ Print _________________________________
Date: ____________ Date: ____________
Form 11 New York City Health and Hospital Corporation CME Committee
The NYC HHC CME and CE Program Committee members listed below will review and approve the program activity for the number of credit hours aforementioned are:
Members:
|Members |
|Abha Agrawal, MD |
|Arnold Merriam, MD |
|Caroline Jacobs, MPH |
|Ines Suarez |
|John Morely, MD |
|Joyce Wale, LCSW |
|Louis J. Capponi, MD |
|Melissa Shori, MD |
|Peter Catapano, DDS |
|Robert Cucco, MD |
|Ross Wilson, MD - Chairperson |
|Van Dunn, MD |
New York City Health & Hospitals Corporation
Continuing Medical Education Committee
Checklist – for CME Programs
Name of Program: _____________________________________________
Program Type: Choose One Single Activity, Regularly Scheduled Series (Grand Rounds, Performance Improvement, Journal Club, Morbidity& Mortality, Review and Update, Break-through Event, IMSAL)
Program Date: _______________________________________________
Length of Program Run: (Choose One) Once, Weekly, Monthly, Annually
Program will run: (Choose One) Once, Weekly, Monthly
|Total CME Credits Requested: |Total Hours of Instruction to Be provided: |
| | |
Number of Presenters: ____
| |YES |NO |N/A |
|Signed Letter of Agreement (If applicable) | | | |
|Copy of Announcement / Advertisement | | | |
|Copy of Agenda | | | |
|Budget form completed | | | |
|Financial Disclosure & Conflict of Interest Forms Signed for each planner and presenter | | | |
|Each presenter CV, or Resume’ included | | | |
|Additional Documents Attached to Application | | | |
|Describe: | | | |
Retrieving CME Continuing Education Credits or Certificate of Attendance
1. Once you completed the educational activity go to the Click on to the NYCHHC CME website
2. Look for the Login section ( on the right side)
3. Enter your username (your email address that you entered on your evaluation form)
4. Enter your password ( usually your first name)
5. Click on to the Go button.
6. The next screen will bring you two buttons. “My Programs” and “CME Tracker”
7. Click the button “CME Tracker”
8. On the same row look to your left. There is a select year with the year 2010. Click on the down arrow to view all of your certificates or just click the down arrow and select the year you want.
9. Once you click the year. You will see the listing of your certificates. You can view or print your certificates by clicking on the view/print button.
10. If you have any questions or problems contact via email
Alfreda Weaver: Alfreda.weaver@
Elizabeth Pierre: Elizabeth.pierre@
-----------------------
[pic]
CME.
Please complete the following statement by circling the number that describes your rating.
CME credits or Certificate of Attendance will not be awarded unless evaluation form is completed, legibly signed and submitted at the end of the learning session.
[pic]
[pic]
CME.
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.