CME Mission Statement: The mission of the Continuing Medical Education (CME) Program is to provide practicing physicians and other health care professionals with the translation, diffusion and application of measurable changes to enhance practice outcomes. This will be done by addressing physician’s professional practice gaps and needs, and improve physician competence and performance in the skills necessary to provide optimal outcomes in patient care.

 

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* 1. Activity Title

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* 2. Activity Director

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* 3. Activity Director Email

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* 4. Ohio AAP Staff Member

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* 5. Proposed Activity Date

Date

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* 6. MOC Part 2 Requested?

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* 7. What type of activity do you think will best achieve that goal?

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* 8. Why is the format you chose the best option?

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* 9. If you chose live activity, please select the following: 

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* 10. Proposed activity location

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* 11. Please select the core competencies that will be addressed in your program:

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* 12. How many credits with this activity contain? (CME & MOC Part 2 must have equal points)

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* 13. Please list the name of all individuals that have control of the content and their role; each of these individuals will be required to complete the Conflict of Interest for at: https://www.surveymonkey.com/r/OhioAAPCOI

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* 14. Please provide a description, including topics, evaluation method, education modality, and overall goals (150 words or less). What’s the problem you are trying to address?; How do you know it’s a problem?; What do you think is contributing to the problem?

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* 15. How will you be evaluating the course? How will you know if you’ve been successful? Please be specific.

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* 16. What are you seeking to change?

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* 17. Which of the following outcomes will be measures? Elect as least one.

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* 18. I will send a 3 month post evaluation to attendees to assess change in the practice baed on objectives learned.

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* 19. MOC Part 2 ONLY: Learning assessment tool

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* 20. MOC Part 2 ONLY: Learner assessment description, please include what the passing standard is for the learner assessment mechanism. Examples are multiple choice question test, passing score, small group discussion, observation, and feedback during simulation:

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* 21. MOC Part 2 ONLY: A description of the process by which feedback will be provided to learners; and if credit has been awarded, verification that the learner(s) successfully met the passing standard for the activity. Feedback to the participant must include learner results with rationale for correct answers or attainment of applicable skill(s) and include relevant citations where appropriate.

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* 22. Will you be seeking commercial support?

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* 23. From which companies are you seeking commercial support? Only if you selected yes to the above question.

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* 24. Will you have exhibits/vendors?

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* 25. All decisions related to the planning, faculty selection, delivery, and evaluation of accredited education are made without any influence or involvement from the owners and employees of an ineligible company.

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* 26. The activity is free of marketing or sales of products or services. Faculty will not actively promote or sell products or services that serve their professional or financial interests during accredited education.

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* 27. All recommendations for patient care in accredited continuing education must be based on current science, evidence, and clinical reasoning, while giving a fair and balanced view of diagnostic and therapeutic options.

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