Application for Certification for AMA PRA Category 1 CME Credit(s)™
Office of CME
1. Applicant(s): ______
2. Title of Activity: ______
3. Date of Activity: ______
4. Location: ______
5. Name of physician(s) responsible for the activity: ______
6. AMA PRA Category 1 Credit (s)™ requested: ______
7. Please provide your planning process for this activity by completing the appropriate attached Worksheet.
Specifically for Single Subject Programs (e.g. symposia) or Recurring Series (e.g. Tumor Board) that are going to address a single or just a few problems (gaps) please complete Worksheet A. For Recurring series (e.g. Grand Rounds) that will have multiple activities each addressing different problems (gaps) please complete Worksheet B. Be sure to address each of the questions asked in the respective worksheet. The completed Worksheets should be submitted along with this application.
Please note that for Recurring Series with multiple activities each addressing a different problem (gap), the speaker for each individual activity in the series will need to complete and submit both the Disclosure Form as well as the Speaker Planning Form prior to the activity in order for it to be eligible for CME credit.
The Design Objectives and Needs Assessment document may help you with formulating Objectives.
8. Enclose/attach a copy of each of the following:
· Learning objectives
· Activity agenda (including topics, times and listing of faculty with title and institutional affiliation of each)
· The proposed budget
· The evaluation form that will be used for the activity
· Planner’s Disclosure Form for anyone involved in planning content (e.g. Program Committees)
9. The Accreditation Council for Continuing Medical Education (ACCME) requires that the content of the CME program is under the control of the accredited sponsor (Chicago Medical School). Please indicate the status of the program being submitted for CME certification: Please þ the box.
£ The program is open to co-planning by the applicant organization and by Chicago Medical School. It is understood and agreed that Chicago Medical School will have the freedom to modify the program as it deems appropriate for CME certification. If the modifications are unacceptable to the applicant organization, the application will be withdrawn.
£ The program has already been created, or largely created, but Chicago Medical School will have the freedom to review and modify the program as it deems appropriate for CME certification. If the modifications are unacceptable to the applicant organization, the application will be withdrawn.
£ The program is open to review but not modification by Chicago Medical School. It is understood that Chicago Medical School may decline to consider applications under these circumstances and would reject applications for which appropriate modifications could not or would not be effected.
£ Other proposed arrangements (please describe):
10. Check all of the following that apply if this activity is receiving financial support from a commercial company:
_____ A signed letter of agreement with the commercial organization, in compliance with ACCME, has been completed.
_____ All speakers: £ have signed, or £ will sign, disclosure statements (statements to be sent to the Office of CME).
þ No commercial exhibit or promotional materials will be allowed in the lecture hall.
þ If accepting Commercial support, it will be acknowledged on activity materials and brochures as follows: "This activity is supported in part by an educational grant from XYZ Company".
þ The applicant organization has complete financial responsibility for this activity. The activity’s budget summary, using the attached form, will be sent to the Office of CME with other follow-up materials after the activity).
11. Additional comments:
12. Contact person of the applicant organization submitting this application:
Name: ______
Title: ______
Address: ______
City: ______
State: ______Zip: ______
Telephone: ( ) ______
Fax: ( ) ______
eMail: ______
______Date: ______
Signature of the applicant organization’s CME Chair/Coordinator or contact person
Chicago Medical School at Rosalind Franklin University of Medicine and Science reserves the right to decline review or acceptance of applications based on the priorities and provisions of the University or Medical School’s mission statements or on the basis of other features regarded as unsuitable by the University or Medical School.
Send completed Application to:
Elsa Kurien, MA, MEd
Director for CME
Office of CME
Rosalind Franklin University of Medicine and Science
3333 Green Bay Road
North Chicago, IL 60064
Telephone: (847) 5783341 Fax: (847) 5783320