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1. Submitter Information

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2. Title of the Proposed Course

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3. Purpose of the Course
Please provide a simple, high-level sentence describing what the course is meant to teach and for whom

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4. Learning Gaps 
What knowledge gaps is this course meant to address? How were the gaps identified? Are there any recent regulatory or industrial changes that led to the need for such a course (e.g. requirement for certification to provide an opinion about fitness, new technology like nanotechnology)

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5. Intended Audience
Describe the primary target audience and something about their demographics (US, global, type of professional, age range), baseline knowledge on topic and anticipated comfort with online learning technology. Describe the secondary target audience (e.g. those who might benefit from some of the modules in the course, but perhaps not all)

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6. CME Market Analysis
Describe the pool of users who would benefit from this course, other than occupational medicine physicians. Are there stakeholders other than health care providers that may also take this course (i.e. legal professionals, HR, safety, etc.) Would this course be appropriate for advanced practice providers (PA or NP) or other types of medical specialists? Describe competing courses if known. Share support materials indicating need for this course in primary and secondary market.

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7. How does this relate to any other current ACOEM courses?
Describe whether this course would be an alternative to another current course, would build on another course, might serve as an introductory course for a more advanced current course, or otherwise relate to a live or online course currently offered by ACOEM (or offered in the past.) For a list of current ACOEM courses, click here.  If not applicable, state so.

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8. Course Director

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9. Please list any secondary faculty serving as subject matter experts
Include name, email address, credentials, and briefly describe their qualifications in relation to the content.

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10. Learning Objectives
Describe the primary high level learning objectives. This would normally be 3 to 5 sentences, and describe what the learner should be able to do after taking this course. Use active words, rather than words like “understand”.  For more information on writing learning objectives, click here.

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11. Which of the following competencies does will this course plan to address?
Select all that apply

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12. Continuing Medical Education (CME) Hours
How many hours of learning will this course offer? Credit is designated based on the average time it would take a small sample group of the target audience to complete the material. Consider time to go through the online course, read associated documents or do research, perform exercises, interact in forums, take quizzes, or other course activities, as applicable. ACOEM staff will verify the CME count prior to the course being finalized.  Has the content already been approved for continuing medical education or other professional accreditation by any other organization? If so, specify.

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13. Measuring Impact
When possible, how will you measure what the participant learned in the course? Will you check baseline knowledge? Will you use knowledge checks throughout the course in the form of quizzes? A test at the end? Any plans to follow-up with participants to see what knowledge was retained or practice changed?

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14. Instructional Delivery Method for Course (overall)

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15. Instructional Strategy
Please indicate what instructional strategies the course will include that fits with the learning strategy of:
  • Absorb (narrated slides, reading, watching videos, listening to podcasts)
  • Do (self-directed research, development/creation of something, quizzes, other interactions that require the learner to make decisions)
  • Connect (discussion forum, web meetings, group projects, reflection on applicability to own practice)

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16. Media
Describe the type of media proposed. If you already have an authoring tool in mind (e.g. Articulate, iSpring, Captivate, etc.), name it. 

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17. What else do you want ACOEM to know about your course proposal, e.g. proposed contract structure, etc.?

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