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CME Activity Application & Planning Worksheet

INSTRUCTIONS

This application must be forwarded to the Wisconsin Medical Society, Office of Continuing Medical Education no later than ninety (90) days prior to the activity start date. All activities must ultimately be approved by the Wisconsin Medical Society Council on Medical Education. Completion of this application is not a guarantee of acceptance by the Council.

GENERAL INFORMATION – Please provide a copy of the program outline/schedule.

Date Submitted:

Society Department:

If outside the Wisconsin Medical Society*:

Organization:

Address:

Phone:

FAX:

E-mail:

Registration or attendance fee charged? Yes NoIf yes, please list amount $TBD

Will this activity receive commercial support? Yes No If yes, please list amount $TBDIf yes, please list source(s) and fill out the commercial support agreement form(s).

Activity Title:

Program Date(s):

Time(s):

Number Credits Requested:

Location:

* If you are an organization outside of the Wisconsin Medial Society and are applying for joint sponsorship of your activity, you are subject to a $1,000 fee for the approval and accreditation of your CME activity.

NEEDS ASSESSMENT

Please describe how the need for this activity was determined. Be as specific as possible. If the purpose of the program is to provide new medical knowledge, list journal references or other sources of the information. Were the participants (or potential participants) consulted or surveyed? If so, please describe how they were consulted. If this is a recurring activity, explain how evaluations from the last session were used to adjust curriculum. All activities are expected to correspond with our general mission.

The purpose of the Wisconsin Medical Society is to advance the science and art of medicine and the health of the people of Wisconsin; ensure that physicians are equipped to deal effectively with the economic and political aspects of practice; and serve as the patient and physician advocate to government and other relevant publics.

WISCONSIN MEDICAL SOCIETYCOUNCIL ON MEDICAL EDUCATION

CME MISSION STATEMENT

The CME mission of the Council on Medical Education of the Wisconsin Medical Society is to enhance the medical care provided to the citizens of Wisconsin through two educational mechanisms:

1. Providing surveillance and monitoring of intrastate agencies which offer Continuing Medical Education (CME) to physicians and other health professionals in Wisconsin.

2. Improve patient care and physician effectiveness by providing accredited CME programs. The content will generally be selected from areas in which the Wisconsin Medical Society has special expertise not generally offered by other CME providers. The target audiences for these activities are physicians licensed in the state of Wisconsin.

When sponsoring or jointly sponsoring CME programs, the Wisconsin Medical Society Council on Medical Education is guided by the principles of requiring valid needs assessment mechanisms, acceptable objectives, appropriate educational designs, qualified faculties and substantive evaluation mechanisms primarily for physicians practicing in Wisconsin.

The educational activities will include conferences, workshops, symposia and other activities as appropriate.

We expect to consistently measure participating physicians' satisfaction with our educational offerings with special attention to their perception of the usefulness of the content in changing practice behavior.

Please explain needs assessment below. (Attach additional pages as needed.)

TARGET AUDIENCE

For whom is the activity intended? Please describe the participants, as specifically as possible. (Attach additional pages as needed.)

EDUCATIONAL OBJECTIVES/PURPOSE

Upon completion of the activity, what knowledge, skills, and/or attitudes should the participants have acquired? Be as specific as possible.

EDUCATIONAL FORMAT

How will the knowledge, skills, or attitudes described in the objectives/purpose be transferred to the participants? [lecture, case presentation, problem based learning, computer assisted instruction, small group discussion, etc.] How are presenters (lecturers, etc.) being informed of the education objectives? Please document this interaction. (Attach additional pages as needed.)

PLANNING MINUTES

Everyone is asked to keep minutes or make notes to illustrate the planning process that took place prior to the activity taking place. Attach a copy of the planning documentation (notes from telephone correspondence or letters related to the planning of the program are appropriate documentation). A copy of the proposed budget, if applicable, should be submitted with this worksheet. (Attach additional pages as needed.)

EVALUATION

How will the participant’s achievement of the educational objectives be measured? [Post-tests, questionnaires, post-program surveys, etc.] Describe the evaluation process to be used and attach a copy of the evaluation instruments (See sample evaluation questionnaire attached). (Attach additional pages as needed).

Note: A summary of the evaluation results and a list of participants must be received in the CME Office within 30 days following the program date(s).

VOLUNTARY DISCLOSURE STATEMENTThe Wisconsin Medical Society has implemented a process where everyone who is in a position to control the content of an education activity has disclosed to us all relevant financial relationships with any commercial interest. In addition, should it be determined that a conflict of interest exists as a result of a financial relationship a speaker may have, this will need to be resolved prior to the activity. In order to do this, a disclosure statement must be completed and returned to the Society with this application. This information is necessary in order for the Society to be able to move to the next steps in planning this CME activity. If a speaker refuses to disclose relevant financial relationships, he/she will be disqualified from being a part of the planning and implementation of this CME activity.

How will speaker disclosures be communicated to the audience? (see attached statement).

WHERE TO RETURN THIS FORM

Return the completed form, or complete the form in Microsoft Word and send the document on disk, along with a copy of the needs assessment data, planning documents, evaluation instrument and program outline to:

Wisconsin Medical SocietyCouncil on Medical EducationPO Box 1109Madison, WI 53701Phone: 608.442.3796Fax: 608.442.3802E-mail: stephant@wismed.org

Brochure Checklist

Activity Title:

Date:

Society Department/Joint Sponsor:

Please use the following checklist to ensure that the invitation, advertisement, or brochure for your program corresponds to the requirements established by the Accreditation Council for Continuing Medical Education, and the Wisconsin Medical Society Council on Medical Education.

CME credit cannot be awarded for activities with brochures that do not correspond to these requirements.

A draft copy of the brochure, invitation or advertisement for the activity, and of this completed checklist must be on file in the CME Office before credits can be awarded. Please call the CME Office at (608) 442-3796 for more information.

The Wisconsin Medical Society must be prominently listed on the front of the brochure as accredited CME provider. The program must be identified as a CME activity of the Wisconsin Medical Society. Departments, divisions, clinics, or hospitals can also be listed as partners or presenters.

Learning Objectives or Statement of Purpose must be listed in the brochure. This is to inform the potential attendees of the activity content.

EXAMPLES:

The objectives of this activity are to: Highlight recent research progress related to lung cancer; Identify current lung cancer treatment options; Review promising clinical research strategies for the next decade;

The purpose of this activity is to review the pathophysiology of pneumonia and current treatment options.

A statement of “Who Should Attend” should be included. This is important information in helping potential participants decide if the activity is what they want and need. Include any pre-requisites.

EXAMPLES:This activity is designed for nuclear medicine physicians, radiologists, technologists and referring physicians.

This symposium has been designed for Primary Care physicians seeking the latest information pertaining to back pain.

The Following Official Accreditation Statements, and no others, must appear in the brochure verbatim with the prescribed number of CME. The Wisconsin Medical Society expressly prohibits use of the expression that “CME certification has been applied for”.

Statements are to be included in all brochures, in separate paragraphs as shown here:

STATEMENT OF ACCREDITATIONThe [name of accredited provider] is accredited by the Wisconsin Medical Society to provide continuing medical education for physicians.

AMA/PRA DESIGNATION STATEMENT[name of accredited provider] designates this educational activity for a maximum of [number of credits] AMA PRA Category 1 Credit(s)TM.  Physicians should only claim credit commensurate with the extent of their participation in the activity.

STATEMENT OF ACCREDITATION - JOINT SPONSORED ACTIVITYThis activity has been planned and implemented in accordance with the Essential Areas, Elements and Policies of the Wisconsin Medical Society through the joint sponsorship of [name of accredited provider] and [name of non-accredited provider]. The [name of accredited provider] is accredited by the Wisconsin Medical Society to provide continuing medical education for physicians.

AMA/PRA DESIGNATION STATEMENT[name of accredited provider] designates this educational activity for a maximum of [number of credits] AMA PRA Category 1 Credit(s)TM.  Physicians should only claim credit commensurate with the extent of their participation in the activity.

Commercial support of the activity must be listed in the brochure. This support should be acknowledged with a statement that the program is “supported by an unrestricted educational grant” from the organization(s).

In most cases, it is best to avoid including logos of drug companies or other vendors. No product names or product logos are permitted. In all cases, care must be taken that the brochure does not include advertisements for anything other than the educational event.

Refund Policy. All CME activities for which a fee is charged must state a refund policy in the promotional material, even if the policy is “no refunds”.

ADA Compliance Statement. All CME promotional materials must include a mechanism for participants to alert organizers to special needs or accommodations required by the Americans with Disabilities Act of 1990 (P.L. 101-336).

EXAMPLES:

[Name of organizer] fully intends to comply with the legal requirements of the Americans with Disabilities Act.  If any participant of the [CME activity title], given by [name of sponsor], is in need of accommodation, please do not hesitate to submit written requests at least _____ weeks priorto the conference to _____.

In accordance with the Americans with Disabilities Act, [name of organizer] seeks to make this conference accessible to all.  If you have a disability, which might require special accommodations, please email your needs to:  _____ or call _____.

[Name of organizer] subscribes to the articles of Title III of the Americans with Disabilities Act of 1990.  Should you are anyone accompanying you require special assistance, please notify us by contacting _____

EVALUATION OF CME ACTIVITY

Activity Title:

Presenter:

Date of Activity: Approved category 1 credit(s):

Location of Activity:

Purpose/Objectives: [objective 1] [objective 2] [objective 3]

Yes No1. Did this activity meet the stated objectives/purpose?

2. Will this activity alter my practice performance?

3. Did this activity meet my expectations?

4. Was this program balanced and free from commercial bias?

5. Did the speaker do an adequate job of presenting? Comments:

6. Choice of Location: Excellent Good Fair Poor

7. The greatest strength of this activity was:

8. The greatest weakness of this activity was:

9. Topics for future continuing medical education activities:

<SPEAKER NAME> has completed a Disclosure of Relevant Financial Relationships form and has no relationships to disclose (or appropriate statement). This educational activity has no commercial support (or appropriate statement).

In order to receive CME credit, please complete this form and return to us at the end of the conference, mail to the Wisconsin Medical Society, Attn: CME, PO Box 1109, Madison, WI 53701, or fax to: (608) 442-3802. Thank you.

Printed Name: Address (for certificate):

Credits claimed (if less than maximum):

The Wisconsin Medical Society is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.The Wisconsin Medical Society designates this educational activity for a maximum of (#) AMA PRA Category 1 Credit(s)TM.  Physicians should only claim credit commensurate with the extent of their participation in the activity.

Disclosure of Relevant Financial Relationships

Name: Name of faculty member/author/teacher/planner

Content of Activity: Title and/or summary of content

Date of Activity: Date of activity

First, list the names of proprietary entities producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours.

Second, describe what you or your spouse/partner received (ex: salary, honorarium etc). The Wisconsin Medical Society does NOT want to know how much you received.

Third, describe your role.

Commercial Interest

Nature of Relevant Financial Relationship (include all those that apply)

What was received? For what role?

Example: Company “X” Honorarium Speaker

I do not have any relevant financial relationships with any commercial interests.

Date Form Completed:

Example Terminology

What was received: Salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.

Role(s): Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and ‘other activities (please specify).

FOR WISCONSIN MEDICAL SOCIETY USE ONLY:

On-site disclosures made by CME Representative initials/date

Glossary of Terms

Commercial InterestThe Wisconsin Medical Society defines a “commercial interest” as any proprietary entity producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies.

Financial relationshipsFinancial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. The Wisconsin Medical Society considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

Relevant financial relationships The Wisconsin Medical Society focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. The Wisconsin Medical Society has not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The Wisconsin Medical Society defines “’relevant’ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

Conflict of InterestCircumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.

WRITTEN AGREEMENT FOR COMMERCIAL SUPPORT

The Wisconsin Medical Society (Society) is committed to presenting CME activities that promote improvements or quality in healthcare and are independent of the control of commercial interests. As part of this commitment, the Society has outlined in this written agreement the terms, conditions, and purposes of commercial support for its CME activities. Commercial Support is defined as financial, or in-kind, contributions given by a commercial interesti, which is used to pay all or part of the costs of a CME activity.

Title of CME Activity:

Activity Location: Activity Date:

Name of Commercial Interest:

Amount of Educational Grant (direct or in-kind):

Grant will e used for the following:

Speaker Honoraria Speaker Expense (itemize) Meeting Expenses (itemize) Other (list)

Terms, Conditions, and Purposes

Independence1. This activity is for scientific and educational purposes only and will not promote any specific proprietary business interest of the Commercial

Interest.2. The Accredited Provider is responsible for all decisions regarding the identification of educational needs, determination of educational

objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content of the CME, selection of education methods, and the evaluation of the activity.

Appropriate Use of Commercial Support3. The Accredited Provider will make all decisions regarding the disposition and disbursement of the funds from the Commercial Interest.4. The Commercial Interest will not require the Accredited Provider to accept advice or services concerning teachers, authors, or participants or

other education matters, including content, as conditions of receiving this grant. 5. All commercial support associated with this activity will be given with the full knowledge and approval of the Accredited Provider. No other

payments shall be given to the director of the activity, planning committee members, teachers or authors, joint sponsor, or any others involved with the supported activity.

6. The Accredited Provider will upon request, furnish the Commercial Interest documentation detailing the receipt and expenditure of the commercial support.

Commercial Promotion7. Product-promotion material or product-specific advertisement of any type is prohibited in or during the CME activity. The juxtaposition of

editorial and advertising material on the same products or subjects is not allowed. Live or enduring promotional activities must be kept separate from the CME activity. Promotional materials cannot be displayed or distributed in the education space immediately before, during or after a CME activity. Commercial Interests may not engage in sales or promotional activities while in the space or place of the CME activity.

8. The Commercial Interest may not be the agent providing the CME activity to the learners.

Disclosure9. The Accredited Provider will ensure that the source of support from the Commercial Interest, either direct or “in-kind,” is disclosed to the

participants, in program brochures, syllabi, and other program materials, and at the time of the activity. This disclosure will not include the use of a trade name or a product-group message. The acknowledgment of commercial support may state the name, mission, and clinical involvement of the company or institution and may include corporate logos and slogans, if they are not product promotional in nature.

The Commercial Supporter and the Society agree to abide by all requirements of the Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support of Continuing Medical Education (appended).

Name of Accredited Provider:

Tax ID Number:

Contact Person: Email Address:

Phone Number: Fax Number:

Educational Partner (if applicable):

Tax ID Number:

Contact Person: Email Address:

Phone Number: Fax Number:

Name of Commercial Interest:

Tax ID Number:

Contact Person: Email Address:

Phone Number: Fax Number:

Agreed by Authorized Representatives

Commercial Interest

Signature and Date

Print Name and Title

Accredited Provider

Signature and Date

Print Name and Title

Educational Partner/Joint Sponsor (if applicable)

Signature and Date

Print Name and Title

i The Wisconsin Medical Society (Society) defines a Commercial Interest as any proprietary entity producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies. The Society does not consider providers of clinical service directly to patients to be commercial interest.