Department Centered Activity & Jointly Provided Activity Checklist
NAME OF DCA/JPAACTIVITY:
DATE(s) OF ACTIVITY:
DEPARTMENT/ORGANIZATION:
FROM: EMAIL: PHONE:
CHECKLIST SUBMISSION DATE:
TO: UHS PEP Representative
STEP 1
ITEMS TO BE SUBMITTEDBEFORE ANY PROMOTION
Please submit all documentation at one time via email. If any item does not apply, writeN/Aon the line.
Check if this program:
A. _____WILL _____ or WILL NOT be applying for GRANTS
Note: Grants awarded by non-profit organizations are not considered commercial support
B. _____WILL _____ or WILL NOT seek IN-KIND SUPPORT (example: equipment loans, supplies, etc.)
C._____WILL _____ or WILL NOT plan to host EXHIBITS
D._____WILL _____ or WILL NOT use VCU Health CME Online Registration System
E._____WILL _____ or WILL NOT use VCU CME Health Online Evaluation System
F._____WILL _____ or WILL NOT use VCU CME Health Online Participant Self-Serve Attestation & Certificate
_____ Completed, signed, CME Activity Application(Must be received at least 45 work days prior to activity)
- Gap Analysis – Please make sure ALL questions are complete.
- Needs Assessment – suggested items include but are not limited to emails, surveys, planning meeting minutes, data reports, or citations thereof, journal articles, new guidelines. Please document how/why these topics were chosen.
_____ DRAFT Program Agenda with schedule, including times/breaks/lunch, etc. –Submit with CME Application
*This draft must include educational objectives, speaker names and affiliations.
_____ Completed & signed COI forms for ALL PLANNERS- Submit with Application in ALPHA order)
_____ Resolution of Conflict(s) of Interest Form for all PLANNERS – Submit in Alpha order with CME Application
To be completed by the Activity Director (or designee) for those who indicated a relevant conflict of interest on the COI form.
_____ Review /Approval of any SAVE THE DATE ANNOUNCMENT if applicable.
*All COI forms for the program’s Activity Director and all Planners must be received by UHS-PEP BEFORE credit
is designatedand any promotional materials are published/distributed.
Department Centered Activity & Jointly Provided Activity Checklist
NAME AND DATE OF DCA/JPA ACTIVITY:
CHECKLIST SUBMISSION DATE:
STEP 2
ITEMS TO BE SUBMITTED FOR REVIEW APPROVAL: Submit at least 4 weeks prior to activity date.
Please submit all documentation at one time via email. If any section does not apply, write N/A on the line.
_____ Signed Letter of Understanding (LoU) between UHS-PEP and Department/Organization
*Sent to your department AFTER CME Activity Application is received, reviewed, and approved by UHS-PEP
_____ Final Program/Brochure - for Review and Approval before being distributed
_____ Speaker/Faculty Conflict of Interest Disclosure (COI) Forms - Submit in ALPHA order
_____ RESOLUTION of Conflict(s) of Interest form for PRESENTERS
*N/A if no speakers indicate a relevant conflict- Submit in ALPHA order, if none write N/A
Resolution forms are completed by the Activity Director (or designee) for presenter(s) with relevant conflict(s) of interest. If this review cannot be completed before the activity, the presentations cannot be designated for CME credit, and the total credits for the program will be reduced.
_____ Draft of Evaluation Formfor Review and Approval
* N/A if using VCU Health CME Online Participant Self-Serve Attestation & Certificate
_____ Draft of Verification of Participation (VOP)for Review and Approval – to be distributed to & collected from
eachattendee at the activity.
* N/A if using VCU Health CME Online Participant Self-Serve Attestation & Certificate
_____ CV or NIH Bio-sketch for ALL non-VCU Faculty/Speakers - Submit all in ALPHA order
Department Centered Activity & Jointly Provided Activity Checklist
NAME AND DATE OF DCA/JPA ACTIVITY:
CHECKLIST SUBMISSION DATE:
STEP 3
ITEMS TO BE SUBMITTED FOR REVIEW & APPROVAL: Submit at least 3weeks prior to activity date.
Please submit all documentation at one time via email. If any section does not apply, write N/A on the line.
_____ Speaker/FacultyConflict of Interest Disclosure (COI) Announcement –
*MUST be presented to all attendees either by printed handout or powerpoint slide. If no conflicts, must share this with attendees as well.
View template on website:
_____ Acknowledgment of Commercial/In-Kind SupportAnnouncement –
*MUST be presented to all attendees either by printed handout or powerpoint slide. If no commercial/in-kind support, must share this with attendees as well.
View template on website:
The items below apply only if you have grants and/or exhibits:
If you are applying for Independent Medical Education Grants: (please refer to activity LoU for other requirements), VCU Health CME must approve, in advance:
1) All applications/submissions for grants
2) Letters of Agreement for Commercial Support and sign as accredited provider
_____ Verification of Commercial Support Form – *Submit only if you have grants and/or exhibits
View template on website:
Department Centered Activity & Jointly Provided Activity Checklist
NAME AND DATE OF DCA/JPA ACTIVITY:
CHECKLIST SUBMISSION DATE:
STEP 4
PROGRAM CLOSE-OUT ITEMS: Send within 10 days after program with Activity Checklist.
Please submit all documentation at one time via email. If any section does not apply, write N/A on the line.
_____ Copy of final program syllabus and all instructional materialsdistributed
REQUIRED - submit a final hard copy to PO Box 980048 Richmond, VA 23298
Orhand deliver to VCU Health CME at McGuire Hall ANNEX, 1112 East Clay St. 2nd Floor, Room 226
_____ Verification of Participation (VOP) Forms - Submit via email or mail all in one package in ALPHA order
* N/A if using VCU Health CME Online Participant Self-Serve Attestation & Certificate
_____ Custom Data Import Excel Spreadsheet with required participant data – Submit via email attachment
* N/A if using VCU Health CME Online Participant Self-Serve Attestation & Certificate
_____ Exhibit Confirmations– Send copies of all Confirmation Forms if applicable.
* N/A if this does not apply.
The items below are to be sent no later than30days after the program is over:
_____ Tabulated Evaluation Results Data- N/A if using VCU Health CME Online Evaluation
_____ Financial Summary