A Credit Request J V.8.03



CREDIT REQUEST FOR DIRECTLY SPONSORED DERIVATIVE (ENDURING MATERIAL) OF A LIVE CONTINUING MEDICAL EDUCATION ACTIVITY

This document is for use by UCSF faculty to request AMA Physician’s Recognition Award category 1 credit for an enduring material derived from a live continuing medical education activity directly sponsored by the UCSF School of Medicine or for the recertification of an existing enduring material. UCSF is accredited by the ACCME to provide CME for physicians. If you have questions regarding the completion of this form or its companion documents, please contact the Office of Continuing Medical Education.

|Plan: F (Enduring Material Supplement) |

|Course Number (OCME use only):       | |Today’s Date: |

|Enduring Material Title: |      |

|Activity on which the Enduring |      |Course number of original activity: |      |

|Material is based: | |      | |

|Department/Division: |           | | |

|Enduring Material Chair |      | | |

|Mailing Address: |      |Phone:       |      |

| |      |Fax:       |      |

| |      |E-mail:       |      |

|Administrative Contact:       |      | | |

|Mailing Address:       |      |Phone:       |      |

| |      |Fax:       |      |

| |      |E-mail:       |      |

|Activity Site: |      |

|Term of Enduring Material (Activity | | | |

|Date(s): | | | |

|Release Date |           |Term may not exceed three years      |

|Termination Date: |      | | |

|Total Credit Hours Requested: |      | | |

|Other Specialty or Mandated Credits |      | | |

|Requested (see core sheet for | | | |

|examples) | | | |

Departmental Approval and Financial Agreement

This request for credit for an enduring material is submitted for CME credit review by the Department of (or if a Department of Medicine course, Division of) _ ___, UCSF School of Medicine, in full compliance with ACCME accreditation requirements, UCSF policies, and OCME business practices. The Department (or if DOM, Division) understands and agrees to pay OCME accreditation, registration, and event planning fees (when appropriate). The Department (or if DOM, Division) retains final financial responsibility for any course loss and will receive any course surplus.

Departmental (divisional) NCA/Fund/DPA for payment to OCME:      

[pic]

If approved for CME credit, the financial obligations noted below will apply:

• CME Accreditation and Oversight Fee $500

• Registration Fee $ 25 per registrant

• Program Management Fee 10% of proceeds from

I concur:      

Activity Chair (PRINT NAME & SIGN) Date

I concur:      

UCSF Department Chair or Division Chief (PRINT NAME & SIGN) Date

Attach a copy of the credit request and the approval letter from CME for the original activity from which this enduring material is derived.

I. PLANNING

A. Planning Committee: Is the planning committee membership for the enduring material the same as for the live activity?

YES NO

If YES, list committee members below.

|Planning Committee Member’s Name |UCSF School of Medicine Faculty? |Academic Title |Akkkk |

| |Please indicate. | | |

|1.      | Yes | No |      |

|2.      | Yes | No |      |

|3.      | Yes | No |      |

|4.      | Yes | No |      |

|5.      | Yes | No |      |

Include additional planning committee members with their faculty affiliation and academic title below if necessary.

     

B. Planning Process: Describe the planning process led to the decision to offer this enduring material. Describe how the planning process links the identified educational needs with the activity's desired result. Attach planning committee minutes or notes, e-mail correspondence, and/or other supporting documentation.

NEEDS ASSESSMENT

A. Did the needs assessment for the enduring material differ from that of the live activity?

YES NO

If YES, describe the differences.      

What methods were used to identify the educational need for this activity? (Check box for each method used and attach copies of needs assessment documentation.) Use of data from multiple sources (demonstrated, expressed, presumed) is encouraged.

|Demonstrated need: |

| |

|Literature review regarding home study (i.e., journal articles, Medline search results) |

|Public health data |

|Other:       |

| |

|Expressed need: |

|Previous evaluation summary |

|Focus group evaluation |

|Target audience survey |

|Other:       |

Presumed need:

Presentations at national meetings

New procedure (provide description of new procedure in II.B below)

Opinion / experience of planning committee (describe II.B below)

Input from other experts

Other:      

Summarize the needs assessment data obtained by methods designated above. Please cite all relevant primary date and or citations with the credit request.

III. EDUCATIONAL DESIGN

A. Target Audience: Explain how the target audience for the enduring material activity differs from the audience for the live activity.      

B. Purpose and Educational Objectives: Use the same purpose and/or educational objectives as the live activity. Explain how the objectives will be conveyed to the audience.      

C. Attach a schedule for the live activity that will be developed into an enduring material

D. Describe the presentation method(s) of the enduring material

DVD/Video CD ROM Monograph/Journal Article Audio Tape

E. Evaluation and Outcome Measures: Indicate the methods to be used (check all that apply)

|1A. |Post-course Evaluation Form2 |

| |Assessing potential for commercial bias (required) |

| |Assessing participants’ satisfaction with activity |

| |Asking participants to estimate activity’s impact on their practice patterns/patient care |

| |Other (describe):       |

| | |

|1B. |Other Evaluation Measures | | |

| |Pre/Post-Tests (using an audience response system) |

| |Pre/Post-Tests (written) 2 |

| |Skills Measurement (procedure performance/device manipulation) |

| |Quality Assurance Review |

| |Chart Reviews |

| |Utilization Review |

| |Post-Activity Survey (3-12 months post course) |

| | | | |

| |2 Attach all sample(s) of evaluation tools |

| | |

|2. |How will you use the data obtained from the evaluation method(s) checked in #1 above: |

| |Summary of data for reporting to UCSF Office of CME and feedback to speakers |

| |Review of summary data as part of needs assessment for next year’s activity/new activities |

| |Outcomes evaluation to assess activity’s direct impact on physician performance |

| |Outcomes evaluation to assess activity’s direct impact on patient care |

IV. PROGRAM ADMINISTRATION AND RESOURCES

A. Budget: Attach a preliminary budget. Estimate revenue (registration, grants, etc.), identifying commercial or foundation grantors by name and estimated grant amounts (monetary or in kind). (If grantors are not yet confirmed, list companies solicited in text field below.) Estimate expenses (honoraria, production costs.). If this is a repeat activity, also include a final financial statement from the most recent offering, indicating names of grantors and amounts of grants awarded under “Revenue.”      

B. Commercial Support: Will the activity receive commercial support separate from the original activity?

Yes No (If commercial support has not yet been confirmed, identify names of grantors you anticipate approaching in IV.A above.)

Describe how commercial support for both the original activity and the enduring material will be acknowledged to participants, check all that apply:

Syllabus Brochure UCSF CME Web calendar Other

Attach sample commercial support agreement. Provide copies of any completed, signed commercial support agreements for grants that are secured.

Faculty Disclosure: Indicate how faculty credentials (names, titles and affiliations) and disclosures (significant financial relationships with industry) will be communicated to the audience prior to the presentation. Check all that apply:

| |Syllabus | | |

| |Opening Slide | | | | |

| | | | | | |

D. Disclosure of Fees: Indicate the projected cost to participants for this activity, and describe how the target audience will be informed in advance.

E. Distribution: How will the enduring material activity be distributed to the target audience?

Direct Mail Hand Delivery (explain by whom and how):

Online Email or postcard Response to Request Materials Other (explain):      

F. Activity Completion: Describe how the learner will complete the activity and request CME credit, e.g., completion and submission of a posttest.

G. ACCME Requirements for Notice: Describe how the activity will meet the following requirements for providing advance notice to the learner of the full terms of the activity including

1. Principal faculty and their credentials;

2. Medium or combination of media used;

3. Method of physician participation in the learning process;

4. Estimated time to complete the educational activity (same as number of designated credit hours);

5. Dates of original release and most recent review or update; and

6. Termination date (date after which enduring material is no longer certified for credit).

Submit the completed credit request no later than four weeks before promotion begins for the proposed activity. Upon completion of the review by the UCSF CME Governing Board, a letter with the Board’s decision will be sent to the Activity Chair.

CHECKLIST Have you included?

Departmental NCA/Fund/ DPA for payment of accreditation and registration fees

Signatures of activity and department chairs

Core Sheet

Planning documentation (meeting minutes, e-mail correspondence)

Needs assessment supporting documentation (cited in II.B or attached; see II.A above)

Activity program/schedule indicating specialty or other mandated credits (see III.A-D above)

Evaluation tool including a bias question(see III.E above)

Projected budget showing grantor names and amounts (and prior year’s financial statement if repeat course; see IV.A above)

Sample commercial support agreement (if support has been or will be sought)

Sample faculty disclosure form (and copy of prior year’s syllabus disclosure page if repeat course; see IV.C above)

Description of how required information will be communicated to learners.

Description of how activity completion will be verified.

Return the completed form with supporting documentation to:

Manager, Accreditation and Educational Development

Office of Continuing Medical Education

3333 California Street, Suite 450

San Francisco, CA 94143-0742

Phone: 415.476.6124

Fax: 415.476.0318

massyk@ocme.ucsf.edu

If you would like more information regarding ACCME criteria, please contact the Office of CME

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download