The Direct Sponsor for your activitiy will be Miami Children's Hospital.
(The mission of the activity must align with the CME Mission of MCH. Please upload the purpose/mission of the activity along with the checklist)
Fields marked with an * are required.
Do you have a written Purpose/Mission of the proposed activity? If NO your application will not be accepted. *
Upload the Purpose/Mission of the proposed activity. (PDF, Word DOC format only) *
Your First Name: *
Your Last Name *
Best Phone Number to reach you on
(Please use numbers only) *
My role is
Course Director (if not you)
Director Phone Number
Coordinator Name (if not you)
Start date (MMDDYY)
End date (MMDDYY) *
Start time *
End time *
City, State *
Type of Activity
(Formats; Check all that apply) (C5)
If Other Delivery Method specify.
Desired number of AMA PRA Category 1 Credit Hours
List below the individuals who are involved in planning this activity. This must include Activity Director and CME chair all supporting staff and moderators. Please use this format: (Name, Affiliation, Has Disclosure form been filled by committee members YES or NO) *
The primary group of physicians for this educational activity will be designed and directed to will be:
If Other please specify:
Do the contents of activity match learners’ current/potential scope of practice (C4)
NEEDS ASSESSMENT REQUIRED BY THE ACCME (C2)
Needs assessment data from multiple sources MUST be used to plan all CME activities. Supporting documentation MUST be included with the application, including meeting minutes, notes of peer discussions, identified practice gaps of learners, etc.
Other Observed Needs:
NEEDS ASSESSMENT SUMMARY STATEMENT Needs assessment is the systematic process of gathering information and using it to determine instructional solutions to close the gap between actual and optimal knowledge. In a SUMMARY paragraph, describe specific needs or problem areas that were identified. Explain the plan for addressing the identified knowledge gap. (GAP: What learners know & do (Actual) --> What learners should know & do (Optimal))
Which of the following desirable physician attributes the activity is going to address? Check all that apply (C6)
The activity is designed to Change (C3 and C11):
What measurement tool do you intend to use?
Other measurment tool:
What knowledge or skills should the Physician learner be able to apply to his/her practice as a result of this activity? Learning Objectives should aim to change physician competence, performance or patient outcomes and they must be simple, measurable, actionable and relate to the specific needs of this educational activity.
Based on what you hope to accomplish, list three or four things that you would like for the physicians participants to be able to do as a result of their participation in this activity. Attach a separate page if necessary.
Terminology for educational objectives usually begins with "Following this activity, the participant should be able to . . ." , followed by phrases that communicate a performance capability by the participant, verbs such as: describe, analyze, discuss, compare, differentiate, examine, formulate, propose, evaluate, assess, measure, select, and choose. If additional space is required, please submit educational objectives as an attachment.
ACCME Standards for Commercial Support (C7-C10)
It is the policy of the Miami Children’s Hospital to ensure balance, independence, objectivity, and scientific rigor in all directly or jointly sponsored educational activities. All individuals who are in a position to control the content of the educational activity are required to disclose all relevant financial relationships he/she has with any commercial interest(s). These individuals include coordinators, planning committee members, staff, instructors, etc. The ACCME defines relevant financial relationships as those in any amount occurring within the past 12 months that create a conflict of interest. Individuals who refuse to disclose will be disqualified from participation in the development, management, presentation, or evaluation of the CME activity.
Please attest that the coordinator, planning committee members and speakers have been informed of the Disclosure Policy and have agreed to comply with this policy. (Course Director please initial)
The “Disclosure Statement of Financial Relationships” (disclosure form) is the mechanism set-up by the MIAMI CHILDREN’S HOSPITAL to initially collect information to identify and use to begin resolution of potential conflicts of interest (COI). This form must be completed by EVERYONE who has the opportunity to influence the content of the CME activity, including the coordinator, planning committee members, speakers, authors, moderators, etc. Individuals who refuse to disclose WILL NOT be allowed to participate in the CME activity.
Final approval will not be granted until all disclosure documentation is received. Have disclosure forms been completed?
Conflicts of Interest (CIO) must be resolved BEFORE the activity occurs, preferably during the early planning stages.
If COIs were identified, please use the “Resolution of Conflict of Interest Form” to resolve the conflict and submit documentation to the CME office.
Please attest that you have been informed and have agreed to comply with this policy. (Course Director please initial)
How will the audience be informed about disclosures? (A copy must be included with the Activity Closing Checklist.) (Instructions from the Podium Form must be signed and returned to Miami Children's Hospital CME Office)
Other method of disclosure notification to audience, please describe.
Will this activity receive support from Educational grants?
Will this activity receive support from Exhibit fees?
If the activity is supported by a commercial interest:
1) A Letter of Agreement for Commercial Support (LOA) must be signed by both the company’s representative and the CME provider’s representative for all commercial educational grants.
2) The original LOAs or copies must be sent with the Activity’s closing report at the conclusion of the activity.
3) The activity director must submit MCH Standards for Commercial Support Form.
Acknowledgements - Commercial support must be acknowledged to the audience. Miami Children's Hospital has two mechanisms in place to acknowledge commercial support
1) in the printed course materials, a disclosure slide is used to relay any support information to the audience and
2) prior to the start of any activity, the coordinator or moderator verbally acknowledges all commercial supporters.
The Course Director and a representative from Miami Children's Hospital have read the ACCME’s Standards for Commercial Support of CME and understand the guidelines for management of commercial funds.
Participants should have the opportunity to 1) assess the extent that the objectives were met; 2) rate the quality of instruction; 3) confirm professional effectiveness will be enhanced; 4) confirm that disclosures were made; and 5) confirmed that the course content was impartial and unbiased.
What method will be used to assess what the participants have learned as a result of attending this educational activity?
Please upload your proposed evaluation mechanism with this application for pre-approval. (PDF, Word DOC format only)
List the CME activity faculty (name, title, and affiliation)on seperate lines. Attach a separate file with all faculty biographies and Disclosures that are available.
Upload faculty biographies and disclosures in one file. (PDF, Word DOC)
Attach a copy of the proposed schedule with time/topic/speaker/breaks and registration times included.
If no schedule is attached please explain why.
MARKETING AND ADVERTISING
How will notification of this educational activity be distributed to the participants prior to the activity?
If by Website please provide URL:
If by Journal (Title)
If Other, identify:
A copy of the proposed promotional material is attached.
If not, explain
What funds will be used to pay expenses for this activity?
Complete and upload a preliminary budget worksheet or a budget summary (rough estimates are acceptable.) Include all projected revenue and expenses. A final income and expense report is required to finalize the CME accreditation file at the conclusion of the activity.