CME Application

Activity Information

Activity Name

Start Date

End Date

Activity Formats

Course

Internet Live Course

Enduring Material

Internet Enduring Activity

Journal-based

Point-of-Care Learning

Other

City

State & Country

Which credits are you applying for?

AMA PRA Category 1

Maintenance of Certification Part ll

Medical Ethics and/or Professional

Pain Management

Total CME hours requested

Degree(s)

Are you collaborating with other accredited providers on any of the following types of credit? (check all that apply)

Nursing

Physician Assistant

Social Work

Activity Director

Name

Academic Title

Affiliation

Email Address

Phone

Please Click to download, fill and save The Activity Director Compliance Agreement

A signed agreement needs to be uploaded at the Documentation part of this application for Director and for Co-Director or Proxy if applicable.

is there an Activity Co-Director?

Yes

No

If yes Co-Director needs to fill below

Activity Co-Director

Name

Degree(s)

Academic Title

Affiliation

Email Address

Phone

Activity Coordinator/Contact PersonI (if other than Director)

Coordinator Name

Coordinator Academic Title

Coordinator Degree(s)

Coordinator Affiliation

Select the educational need(s) that you determined to be the cause of the professional practice gap(s).

Knowledge (knowing about something)

Competence (the ability to do something; "strategies")

Performance (actually doing something in clinical practice)

Coordinator Email Address

Coordinator Phone

Educational Grants

Will educational grants be obtained for this activity? If so please include grant summary/details [Upload with submission]

Yes

No

Educational Information

Describe how the overall activity plans to address the educational needs that underlie the professional practice gaps of the learners.

Maximum 300 words.

0 / 300

Educational Needs

Knowledge Gap

Describe the knowledge gap.

0 / 300

Please provide a data source(s) to support the knowledge gap.

Data Source 1 {eg survey, scientific evidence}

Data Source 2 {eg survey, scientific evidence}

Competence Gap

Describe the competence gap.

0 / 300

Please provide a data source(s) to support the competence gap.

Data Source 3 {e.g. survey, scientific evidence}

Data Source 4 {e.g. survey, scientific evidence}

Performance Gap

Describe the Performance gap {e.g. survey, scientific evidence}

0 / 300

Please provide a data source(s) to support the performance gap.

Data Source 5- performance gap evidence {e.g. survey, scientific evidence}

Data Source 6- performance gap evidence {e.g. survey, scientific evidence}

Learning Objectives

Describe the learning objective for the gap, i.e., what the learner should be able to do after the educational experience/intervention (apply, select, identify, implement, etc.) Learning objectives should be used both to guide instruction and articulate expectations in terms of measureable changes in knowledge, skills and/or attitudes/behavior. Verbs to Help Formulate Objectives

At the conclusion of the activity, the learner should be able to:

Objective 2

Objective 3

Objective 4

Performance Objectives

Performance Objectives (identify 1-2 behavioral and/or skill changes expected of physician attendees to be used in practice as a result of their participation in the activity; use action verbs, e.g.,

Objective 1

Objective 2

Additional Educational Information

Target Audience (Describe by listing health professions)

Maximum 100 words.

0 / 100

Educational Format (check all that apply).

Lecture

Case Study

Simulation

Texas Children's Hospital

Panel Discussion

Small Group Breakout Session

Skill-based Training Workshop

Other:

Explain why the selected educational format(s) is(are) appropriate for this activity.

0 / 100

Indicate the desirable physician attribute(s) (i.e., competencies) this activity address.

Section Title

Interprofessional Education Collaborative (IPEC)

Values/Ethics of Practice

Roles/Responsibilities

Interprofessional Communication

Teams and Teamwork

N/A

Other competency(ies) (specify):

Planning Committee Members

Please list all members of the Planning Committee. Each Planning Committee member needs to complete a Conflict of Interest form, click to download and fill: https://formlets.com/forms/xn6yzh1QFBx2y1gr/. Upload all Conflict of Intrest at the Documentation part at the end of this form.

Input Table

	Name	Degree	Academic Title	Affiliation	Email Address
1
2
3
4
5
6
7
8

Documentation: Please upload all that applies

Activity Director Compliance Agreement

Activity Co-Director Compliance Agreement if applicable

Conflict of Interest Form: upload COI for all members of the planning committee.

Educational Grant Details (if applicable)

Commercial Support Grid [sponsors, advertising,...]

Evaluation Summary Report (previous year, if applicable)

Additional Documentation [optional]

CME ApplicationFor questions email naama@naama.com or call 248.646.3661

Activity Information

Activity Director

Activity Co-Director

Activity Coordinator/Contact PersonI (if other than Director)

Educational Grants

Educational Information

Educational Needs

Performance Objectives

Additional Educational Information

Section Title

Planning Committee Members

Documentation: Please upload all that applies