Download 7860 Peters Road, F111 • Plantation, Florida 33324 (954) 723

7860 Peters Road, F111 • Plantation, Florida 33324
(954) 723-0057 Phone • (954) 723-0353 Fax
www.naceonline.com • [email protected]
APPLICATION FOR JOINT SPONSORSHIP
OF A CONTINUING MEDICAL EDUCATION ACTIVITY
The National Association for Continuing Education (NACE) is pleased to consider your request to
jointly sponsor the educational activity you are planning for continuing medical education (CME)
credit. Please carefully review the Joint Sponsorship Application and completely answer all the
questions before submitting it to NACE for review. This application must be submitted electronically to
[email protected] at least 90 days prior to the educational activity. Mailed or faxed
applications will not be accepted.
A checklist of all documentation to be submitted to NACE is included at the end of this application.
Use this checklist to keep track of submissions and approvals from NACE.
NACE must accept responsibility for ensuring that all jointly sponsored activities are planned and
implemented in accordance with the Accreditation Council for Continuing Medical Education
(ACCME) Essential Areas and Policies. NACE’s policy on joint sponsorship of CME activities is
based on the following principles:
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All jointly sponsored activities must be for scientific and educational purposes only; the
educational content of jointly sponsored activities must be acceptable by the medical
profession as being within the basic medical sciences, discipline of clinical medicine, and the
provision of healthcare to the public.
As the accredited provider, NACE must be involved in the planning, implementation, and
evaluation of any CME activity for which it chooses to enter a joint sponsorship relationship
with a non-accredited entity.
NACE must review and approve the needs assessment process, activity learning objectives,
design and format of the activity, final faculty selection, and methodology used to evaluate
the activity.
NACE must review and approve all materials associated with the activity prior to their
release.
All jointly sponsored activities must comply with the ACCME Standards for Commercial
Support: Standards to Ensure the Independence of CME Activities, the FDA Final Guidance
on Industry-Supported Scientific and Educational Activities, and the AMA regulations
regarding the Physician’s Recognition Award, the AMA Opinion 8.061: Gifts to Physicians
from Industry, and the AMA Opinion 9.011: Continuing Medical Education.
NACE charges an application fee for each joint sponsored activity. For information about
application fees, contact NACE at (954) 723-0057. Send your completed application to:
NACE, 7860 Peters Road, Suite F111, Plantation, FL 33324 or email to:
[email protected]. Allow two weeks for final approval of applications submitted.
Cordially,
Harvey C. Parker, Ph.D.
Director of Continuing Education
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APPLICATION FOR JOINT SPONSORSHIP
OF A CONTINUING MEDICAL EDUCATION ACTIVITY
APPLICANT:
Organization:
Address:
City, State, Zip:
Contact Person:
Telephone:
Fax:
Email:
Is your organization a commercial interest (any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on,
patients)?
Yes
No
PROPOSED ACTIVITY TITLE:
START DATE OF PROGRAM:
SUBMISSION DATE:
PLANNING COMMITTEE MEMBERS (Include Name and Affiliation):
ACTIVITY SUBJECT MATTER:
Identify the general topic area to be discussed in the activity [i.e. cardiology,
psychiatry, women’s health, lifestyle, etc.].
Define the medical subject(s) to be discussed in the activity [i.e. depression, prostate
cancer, hypertension, dyslipidemia, etc.].
INTENDED AUDIENCE:
Define the target audience [i.e. primary care providers, oncologists, gynecologists,
etc.].
Identify lists and/or sources for audience recruitment or distribution [i.e. society
mailing list, AMA list, supplemental distribution by supporter’s personnel, web-based
advertising, etc.].
EDUCATIONAL PLANNING
List gaps in knowledge, performance or practice that will be addressed by this
activity. (C2)
Identify educational need(s) of knowledge, competence, or performance, derived
from the above professional practice gaps. (C2)
What method(s) were used to determine the educational gaps/needs of the target
audience?
Public Health Data
National or Regional Guidelines
Previous Activity Evaluation Data
New Developments/Techniques
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Survey of Target Audience
Faculty Perception of Need
Literature Search
Other:
Attach a summary of your needs assessment (i.e. literature review, summary of
evaluation data, etc.)
Based on the need/gap(s) identified, what are the desired results of this activity?
(C3)
Change in physician competence
Change in physician performance
Change in patient outcomes
Based on the needs and desired results, list the learning objectives that will be used
to direct the content of this CME activity. (C2)
At the conclusion of this CME activity, attendees will be able to:
Describe how this content matches the learner’s current or potential scope of
professional activities. (C4)
How will this content be delivered? (C5)
Live Formats
Enduring formats
Symposium
Newsletter
Lecture Series
Monograph
Teleconference
DVD
Webinar
Journal
Other:
Internet
Audio/Videocassette
Other:
If a live activity, list dates and locations.
What instructional formats will be used? (C5)
Lecture
Panel discussion
Simulation
Case presentations
Round table
Question and Answer
Other:
How does the format/design of the activity support the activity objectives and
desired results? (C5)
Which desirable physician attributes does this CME activity address? (C6)
IOM Comeptencies
ACGME/ABMS MOC Competencies
delivering patient-centered care
patient care
working as part of interdisciplinary
medical knowledge
teams
practicing evidence-based medicine
interpersonal and communication
skills
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focusing on quality improvement
using information technology
AMA Code of Ethics
professionalism
system-based practice
practice-based learning and
improvement
Other:
How will you address these factors in the design of your CME activity (C6)?
Identify factors outside of our control as a CME provider that may have an impact
on patients outcomes in this disease state. (C18)
Patient compliance and adherence to treatment
Patient understanding of physician instructions
Physician resistance to change
Reimbursement issues
Inadequate access to care
Cost of care
Physician interpersonal communication skills
Other:
How will you address these factors in the design of your CME activity (C18)?
CME ACTIVITY EVALUATION
What method(s) will be used to evaluate if the activity was effective at meeting the
need and desired results as identified above (i.e., creating change in learners’
competence or performance or changes in patient outcomes)? List method(s) for
each type of change indicated. (C11)
CME ACTIVITY DESCRIPTION
Proposed Agenda if live meeting. (Include beginning and ending times of each
lecture, title of each lecture and proposed presenter.)
Proposed content if enduring material:
Number of credits requested:
List potential faculty members and their affiliations.
Describe the process used to identify the proposed faculty.
Prior Working Relationship
Noted Authorities
Literature Search
Clinical Investigator
Input from Medical/Scientific Experts
Other:
COMMERCIAL SUPPORT
List the names of any potential commercial entities that may provide support for the
activity.
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NACE USE ONLY
REVIEW AND CERTIFICATION
This activity has been reviewed and approved for joint sponsorship.
____ Yes or _____ No
The National Association for Continuing Education designates this educational activity
for a maximum of ___ AMA PRA Category I Credit(s)™. Physicians should only claim
credit commensurate with the extent of their participation in the activity.
_________________________
____________
NACE Staff Member
Date
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CHECKLIST OF ITEMS TO BE SUBMITTED TO NACE
Title of CME Activity:
DATE SUBMITTED
DATE APPROVED
ITEM
Joint sponsorship application with full
needs assessment as attachment
SUBMIT THE FOLLOWING ITEMS AFTER THE CME ACTIVITY HAS BEEN
APPROVED AND WITHIN 14 DAYS OF THE MEETING/RELEASE DATE
Disclosure Forms for the Course
Director(s), planning committee
members, faculty members, and anyone
else involved in the planning of the CME
activity
Conflict of Interest Resolution Forms for
anyone listing financial relationships on
the Disclosure Form
CVs for for the Course Director(s),
planning committee members, faculty
members, and anyone else involved in
the planning of the CME activity
Letters of Agreement executed by all
parties for all companies providing
commercial support
Draft brochure and/or marketing
materials to be approved before being
released
Draft handbook and/or meeting materials
to be approved before being released
Draft evaluation form to be approved
before being released (Use NACE
template)
Draft outcomes study to be approved
before being released (Use NACE
template)
SUBMIT THE FOLLOWING ITEMS WITHIN 10 DAYS
OF THE END OF THE CME ACTVITY
List of attendees
Sign-in and Sign-out sheet for live
activities
Spreadsheet of individuals requesting
credit (Use NACE template)
Final brochure/marketing materials
Final handbook/meeting materials
Completed evaluation forms
Summary report of evaluation
Summary report of outcomes study
Reconciled budget
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