Application for Accredited CME Activity

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* Demographic Information

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* 1. What is the purpose of the activity, or problem you are trying to address?

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* 2. How do you know it’s a problem and what do you think is contributing to the problem?

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* 3. What is the difference between the current practice and best practice? (this is the “gap”)

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* 4. What do you need clinicians to do differently? What are you seeking to change?

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* 5. How was this determined? (ie source)

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* 6. What do you hope to be the outcome? (actionable areas that clinicians will do differently in their own clinical practices after the education)

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* 7. Are physicians the intended audience of the activity? If not, who is? What percentage of attendees do you estimate will be physicians?

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* 8. Will there be any commercial support?

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* 9. What will be the general format? (In person activity, Zoom live webinar, case based, possibly small group discussion, QA etc)

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* 10. Why did you choose this format?

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* 11. How do you expect to measure outcome /or change in the learners in order to evaluate success?

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* 12. Provide any additional information that will be helpful to know about your activity.

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