Date of application:

Estimated number of CME credits:

Title of activity:

Date(s) of activity:

Start time:

End time:

Location of activity:

Director of activity:

Department:

Contact name:

Contact phone number:

Contact email address:

Is this a:

series?

one time event?

Is this a joint sponsored activity?

Yes

No

If yes, name of joint sponsor facility and contact person's name an phone number:

Planning committee members names and titles:

**A needs assessment is required to plan CME activities.**
 

What are the gaps in clinical or organizational practice you wish to address with this program? Please explain.

How were the educational needs of this program identified?

Identify the target audience:

Estimate attendance:

How were the professional practice gaps determined?

Please identify the educational need that underlies the professional practice gaps:

The ultimate goal of this session is to improve:

At least 2 objectives per hour of activity should be submitted by the presenter(s).
Identify the educational objectives (what the physician is expected to know or apply at the conclusion of the course. Be sure to use suggested verbs.)

Verbs that inform:
cite, define, describe, identify, list, name, recite, record, recognize, select, state, summarize, update, write

Verbs that convey comprehension:
assess, associate, classify, compare, contrast, demonstrate, describe, differentiate, distinguish, estimate, explain, locate, identify, interpret, predict, report, review
 

These objectives must be shared with the learners and identified in all marketing materials.

Please send additional objective, if necessary to axkoszyk@stvincent.org

Presenter(s) names, titles, and contact information:

It is required that evaluations and pre/post tests be filled out for each CME activity. Please choose an evaluation that meets the needs of your activity. The pre/post test questionnaire must be completed by the presenter(s). Copies of all evaluations and pre/post tests must be submitted to the Medical Education Department following the meeting.

Standard Evaluation (1 presenter)
or
Multi-Presenter Evaluation (one-time events)

Pre/Post Test Questionnaire: It is required that the presenter(s) develop at least two objectives per hour of activity; one question per objective is required. The questions will be compiles into a pre/post test given out at each CME activity. The evaluation and pre/post tests are required in order to obtain CME credit. It is the director/planner's responsibility to obtain these questions/objectives from the presenter(s).

Sample questions can be found here

(If yes, please refer to the "Standards of Commercial Support" found at http://www.stvincent.org/physician/handbook/standards.htm)

Please list the prospective sources of commercial support: