Application for Awarding AMA PRA Category 1 Credit TM

Application for Awarding AMA PRA Category 1 Credit TM

Application for Awarding AMA PRA Category 1 Credit TM

Office of Continuing Medical Education

Connecticut Children’s Medical Center

Connecticut Children’s Medical Center is accredited by the Connecticut State Medical Society to sponsor continuing medical education for physicians.

Section A: General Information
  1. Title of Activity or Program
  2. Accreditation Period:

3Format of CME activity (Check all that apply): Lecture Case discussion

Panel presentation Group discussion, including question and answer periods

Performance of skills under supervision Enduring MaterialAcademic DetailingOther

Frequency of session: Weekly Monthly Quarterly Semi Annually Annual

4Maximum Number of AMA PRA Category 1 CreditTMan individual can receive per academic year.

5Number of Physicians: Number of Non-Physicians:

6Target Audience:

7Date(s) and time(s) of all sessions:

8.Location, address and room #:

Section B:Planners & Speakers

(List all planners and speakers with degrees, titles and faculty appointment.)

1Activity Director:

Name and title:



Phone: Fax:Email:

2Administrative Contact:

Name and title:



Phone: Fax:Email:

(All applications for CME require documentation of the planning process for the educational activity or event. Please append any and all documentation of the planning process to this application. Such documentation can include minutes from meetings, planning notes, and e-mails.)

3List of Planning Committee members and their respective affiliation. Each member of the Planning Committee, including the Activity Director, must complete and submit a “Disclosure Declaration”

Name & DegreeTitle Faculty AppointmentInstitutional Affiliation

4.Speaker Selection

(The term “speaker” applies to a presenter, facilitator, panelist, or any other person serving as part of the educational activity.)

Name & DegreeTitle Faculty Appointment Institutional AffiliationReason of Selection

5. Reasons underlying the choice of specific topics (e.g., result of needs assessment):


Survey or questionnaire of target audience
Discussion of needs at staff or department or specialty society meetings
Key informant interviews with members of target audience
Review of logs or journals kept by target audience
Unsolicited requests or suggestions from target audience
Other (specify): specific review of current patients actively undergoing decision making on repairs on post-operative care and outcomes.

Section C: Needs assessment

  1. Indicate how you assessed the needs of your target audience in preparation for this event. Please check all that apply. Documentation of at least one form of QA/QI-derived needs assessment used in the planning of this activitymust be included before presenting the application to the CME Committee (Objective Source).


QI Findings
M & M Review
Referral Patterns
Chart Audit or other patient care review
Qualidigm Study
Published Professional Resource:
Certification or Board requirements
Surgical calendar of upcoming patients

Which of the Institute of Medicine Competencies does this activity address:

Provide Patient Centered care
Work in Interdisciplinary Teams
Employ Evidence- based practice
Apply quality improvement
Utilize informatics

Section D:Objectives

1. List the overall learning objectives for the activity:

(Learning objectives describe what you want the learning activity to achieve. The objectives should describe specifically, what the attendees would be able to do as a result of attending the program-not what you plan to talk about. Please use words like “define, identify, list” and avoid words and phrases like “understand, become familiar with, and review.”)

2. Describe how the Activity Director will communicate the overall learning objectives and the composition of the target audience to any speakers or faculty responsible for conducting or facilitating the educational activity (check all that apply). Please provide documentation (email and hand-written notes are acceptable) and attach to the Final Report

Written Communication
Verbal Communication

3. Describe how the Activity Director will communicate the overall learning objectives and other important information to the target audience (check all that apply):

Written materials in advance of the activity (e.g. brochure)
Written materials at the start of the activity (e.g., syllabus)
Verbally at the beginning of the activity
Other (please specify): learning objectives will be listed on the weekly notification of conference and topics.
SECTION E: Conflict of Interest

1. Disclosure declarations for the following must be submitted with the application.

  1. Activity Director(s): Financial Disclosure
  2. Planner(s): Financial Disclosure
  3. Speaker(s): Financial Disclosure; Attestation

Please remember to disclose any conflict of interest and the safeguards in place to CME

participants in advance, preferably in writing (e.g., flyer).Verbal disclosure is required for any change from original publicity.

2. Describe the mechanism of making any disclosures

Promotional brochure or flyer
Program handouts
sheet
Verbally (see additional requirements below)
Other – Evaluation form and disclosure slide

Documentation of verbal disclosure must be provided within one month of the activity. In the event of verbal disclosure, a provider representative who was in attendance at the time of the disclosure must attest, in writing that the verbal disclosure did occur and must itemize the content of the disclosed information.

SectionF:Commercial Support

(Commercial support is any financial or in-kind contribution(including refreshments, staffing, equipment and materials) given by a commercial interest to support the cost – in whole or in part – of the CME activity.)

There is no commercial support for this conference

1. Does this CME activity involve commercial support from any commercial interest?

(Check “yes” if any source of support is a pharmaceutical company or medical device manufacturer. The following entities are not considered “commercial” for this purpose: providers of clinical services directly to patients, liability insurance providers, health insurance providers, group medical practices, for-profit hospitals, for-profit rehabilitation centers, and for-profit nursing homes. )

Yes (If “yes” please continue completing this section)
No (If “no” please skip to the next section)

List any and all sources of commercial support and the exact nature of that support additional:

Source of Support


Nature of Support

2. Complete and attach a “Letter of Agreement for Commercial Support” for each source listed.

CMEC approval will be contingent upon our timely receipt of “Letter of Agreement for Commercial Support” for each source listed. (Susan—please verify wording)

3. Exhibits Yes______No ______x______

Section G: Marketing to the Target Audience & Content of Promotional Materials

The Office of Continuing Medical Education must review and approve any promotional material 3 weeks prior to its distribution. Include a sample of promotional material with this application.

Section H:Outcome Measurements:

Activity Director will determine if the audience has learned something at the end of the lecture. Results of one form of outcome measurements will be required for approval of final report and issuance of credit.

Pre & Post Test

Survey Monkey (within one month after the last presentation)

Other (i.e. chart audits)

Section I Evaluation

1. Each CME activity must demonstrate a formal process of evaluating the educational effectiveness of the activity. Please append your draft evaluation form to this application. You may use the sample format provided or design your own. The form must include evaluation components, which will assess:

a)The extent to which educational objectives are met

b)The quality of the instructional process

c)Participants’ perception of enhanced professional effectiveness

d)Participants’ perception of any commercial bias

2. Please indicate how you will use the evaluation data (check all that apply):

Provide summary of feedback to speaker(s)
Provide summary of feedback to participants
Plan future CME activities
Other (please specify):

Section J: Budget

1. List anticipated source and amount of revenue on each line (write “None” if not applicable):

(a) Institutional funds: NONE

(b) Commercial support: NONE

(c) Exhibit fees: 0

(d) Registration fees (provide per person fee and total fee): NONE

e) Other: N/A

f) Total revenue:

2. List estimated expenses: NONE

(a)CME application fee: 0

(b)CME certificate fee ______x $___ =

(c)Honoraria ______x ______speakers

(d)Travel expenses:

(e)Printing: $

(f)Mailing/postage: 0

(g)Room rental for event: 0


(i)Hotel accommodations:

(j)Other expenses (please specify):

(k)Total expenses:

Please complete for each account that will receive any funds or make any payments:

Account Information / Account 1 / Account 2 / Account 3
Name of account
Account number
Person responsible

Section K: Application Signatures:

(Every application requires the signature of the Activity Director. For CME activities officially sponsored by a department {e.g., grand rounds, journal club}, the application also requires the signature of the department chairperson).

As the Activity Director, I attest to the accuracy and completeness of this application, and I accept responsibility for the planning, implementation, and evaluation of this CME. I agree to submit a final report on this activity to the Office of Continuing & Medical Education within six weeks of the event’s completion.
1. Name of Activity Director (printed) Frederic Bernstein
Signature of Activity Director
/ Date: 5
As the Medical Director of Continuing Medical Education, I attest that this CME activity meets the requirements as outlined by the Accreditation Council for Continuing Medical Education.
3. Name of CME Medical Director (printed)
Kenneth Spiegelman, M.D.
Signature of CME Medical Director
/ Date: