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PRE-ACTIVITY REQUIREMENTS.doc

  1. 1. AMERICAN SOCIETY OF ECHOCARDIOGRAPHY APPLICATION FOR JOINT SPONSORSHIP Joint Sponsorship is a relationship between an accredited provider (ASE) and a non-accredited provider (applicant). It is the responsibility of the accredited provider to monitor the educational integrity of the program, ensure that the activity is conducted in accordance with all ACCME guidelines and policies, and offer AMA PRA Category 1 Credits TM.INSTRUCTIONS FOR COMPLETING THE CME APPLICATIONProgram planners are urged to complete the CME application at least six months prior to printing brochuresor other course documents. A preliminary program brochure containing a complete agenda must besubmitted with your application.Needs assessment must be documented and included with your application. Please include survey results,minutes of focus groups or planning committee meetings indicating the origin of the program idea and howthe idea was developed, summary of telephone interviews, etc.Please provide a planning budget, a preliminary program brochure containing a complete agenda with invitedfaculty, and an attendee program and faculty evaluation form with your application. The planning budgetshould include registration fees, number of participants, amount of honoraria, any commercial support, and allfacility costs.Please return the application with the requested documentation attached, along with the application fee of$5,500 to ASE. Applications will not be reviewed unless all requested documentation is included. Paymentmust be received prior to review.You will receive written confirmation that your application has been received at ASE. Applications arereviewed by the CME staff for completeness. Incomplete applications will be returned to you with a checklistrequesting missing information. Complete applications are circulated to the ASE’s ACCME/CME Committeefor their review. The Committee requires at least 10 business days for review of an application. You will benotified, in writing, of the Committee’s decision. No materials may be printed using the ASE name and/or logountil the program has been accepted and the materials have been individually reviewed and approved. Allpromotional materials for ASE sponsored educational activities must be approved by ASE staff in writing priorto printing and distribution.I. INFORMATION ON THE SUBMITTING ORGANIZATIONName of Submitting Organization:      Contact Name:       Title:      Billing Address:      City:       State:       Zip:      E-mail:       1
  2. 2. Phone:       Fax:       A) Additional Sponsor (if any):       Relationship to Submitting Organization (i.e.: course is being offered in cooperation with):       Contact Name:       Title:       Billing Address:       City:       State:       Zip:       E-mail:       Phone:       Fax:       B) Additional Sponsor (if any):       Relationship to Submitting Organization (i.e.: course is being offered in cooperation with):       Contact Name:       Title:       Billing Address:       City:       State:       Zip:       E-mail:       Phone:       Fax:      II. GENERAL COURSE INFORMATIONTitle of Program:      Target Audience(s):      Date(s) of Program:      Location (Facility and City/State):      Number of AMA PRA Category 1 Credits™ (CME Hours) being requested:      Note: Time allotted for registration, breaks, meals, etc. cannot be applied towards credit hours. Pendingreview of the agenda, the actual number of hours approved by ASE may vary.Projected Overall Attendance:      Minimum Attendance:       Maximum Attendance:      Registration Fees: 2
  3. 3. ASE members are to pay no more than 80% of the non-member fees. ASE Physician/Scientist Member:       Non-Member Physician/Scientist:       ASE Non-Physician Member (Cardiovascular Sonographer/Nurse/Student):       Non-Member Non-Physician (Cardiovascular Sonographer/Nurse/Student):      Planning Budget: Please attach a copy of the planning budget. Include registration fees, number ofparticipants, amount of honoraria, any commercial support, and all facility costs. Budget Attached? Yes NoAre any enduring materials being produced from this program for AMA PRA Category 1 Credit™? Yes No UndecidedIII. NEEDS ASSESSMENTStatement of Need (In 2-3 sentences, what need is this activity intended to address? What is the clinicalimportance/significance of the educational content to be presented?):      How was the need documented? Check all that apply.For each item selected, please attached a separate page containing supporting information. Learner Survey Faculty Survey Planning Committee Focus Group Research Data Epidemiological Data Evaluation Summary Past attendee requests New Society/National Guidelines Other (please indicate)      Describe your planning process:      Is this the first time this program has been offered? Yes NoIf no, is this an annual course? Yes NoWhat changes have been made to the current course format, based on the attendee and facultyevaluations from previous courses? Please attach copies of these previous course evaluations.     IV: EDUCATIONAL CONTENTWhat is the overall goal of this program?      Learning Objectives (minimum of 5 required):At the end of this program, participants will be better able to: 1.       2.       3
  4. 4. 3.       4.       5.       6.       7.       8.       9.       10.      Course Description: Please write a 1-2 paragraph course description indicating the educational content tobe presented, the format of the presentation(s), and instructional methodology. This should be the programdescription used in your brochure and onsite syllabus.     What teaching methods will you be using? Didactic Lecture Audience Response System Video Hands-on Workshops Question-and-Answer Small Group Breakout Sessions Case-Based Discussion Panel Discussions Patient Demonstrations Self Assessment Tools Other (please indicate)      Program Agenda and Preliminary Brochure: Please attach a preliminary program brochure containing acomplete, hour-by-hour agenda with invited faculty for each date of the program. Brochure Attached? Yes NoAttendee Program and Faculty Evaluation: Please attach a copy of the questionnaire attendees will use toevaluate the effectiveness of the educational content and the faculty presenters. Evaluation Attached? Yes NoHow do you plan on using the evaluation results?      Do you plan to conduct any future outcomes measurement activities? Yes NoV: FACULTYA CV and current disclosure information for all program chairs and/or co-chairs MUST be included with theapplication. ASE requires that at least the Program Chair must be a current member of the Society. 4
  5. 5. Program Chair/Content Developer*: Name:       Degrees:       Title:       ASE Membership #*:       Affiliation:       City / State:      Co-Chair 1 (if any): Name:       Degrees:       Title:       ASE Membership #:       Affiliation:       City / State:      Co-Chair 2 (if any): Name:       Degrees:       Title:       ASE Membership #:       Affiliation:       City / State:      Other Faculty (include name, degree, title, affiliation, city and state):CV and disclosure information for faculty not involved in the planning process does not need to be providedwith the application. 1.       2.       3.       4.       5.       6.       7.       8.       9.       5
  6. 6. 10.      How do you plan on making the audience aware of the faculty afflictions and any conflict ofinterest/disclosures?      VI. COMMERCIAL SUPPORTWill this program have commercial support? Yes NoIf yes, how do you plan on providing proper recognition and disclosure of supporting companies?     Name Commercial Supporter 1:      Contact Name:       Title:      Billing Address:      City:       State:       Zip:      E-mail:      Phone:       Fax:      Amount of Support Expected:      Name Commercial Supporter 2:      Contact Name:       Title:      Billing Address:      City:       State:       Zip:      E-mail:      Phone:       Fax:      Amount of Support Expected:      Name Commercial Supporter 3:      Contact Name:       Title:      Billing Address:      City:       State:       Zip:      E-mail:       6
  7. 7. Phone:       Fax:      Amount of Support Expected:      Name Commercial Supporter 4:      Contact Name:       Title:      Billing Address:      City:       State:       Zip:      E-mail:      Phone:       Fax:      Amount of Support Expected:      Name Commercial Supporter 5:      Contact Name:       Title:      Billing Address:      City:       State:       Zip:      E-mail:      Phone:       Fax:      Amount of Support Expected:      VII. PRINTED MATERIALSIt is required that you submit a copy of all brochures, flyers, syllabi and other written material for this programto the ASE CME Office prior to printing for our review and approval. The ASE logo must appear on the frontand back of all materials with the following statement “Jointly sponsored by the American Society ofEchocardiography.”How will this activity be promoted? Mailed brochure E-mail Invitations Fax Invitations Printed Advertisements* Save-the-Date Card Other (please indicate)      *Must adhere to ACCME guidelines on advertising.Will you be requesting a copy of the ASE membership list? Yes No Undecided 7
  8. 8. Will you be distributing a printed syllabus for this activity? Yes No UNDERSTANDING THE ROLES AND REQUIREMENTS OF ASE JOINT SPONSORSHIP *A signature indicating that you have read and understood the information below is required.The American Society of Echocardiography is accredited by the Accreditation Council for Continuing MedicalEducation (ACCME) to provide continuing medical education programs for physicians.These policies and procedures are designed to provide guidance for sponsorship of individual CME programsfor AMA PRA Category 1 Credits™. Programs are approved for AMA PRA Category 1 Credits™.Institutions are accredited as providers of continuing medical education for which they may offer AMA PRACategory 1 Credits™. As these are individual programs they will be approved (or denied), not accredited, byASE based upon their compliance with the Essentials of the ACCME and ASE policies.I. CME MISSIONAs an organization dedicated to excellence in cardiovascular ultrasound for patient care, the AmericanSociety of Echocardiography strives to promote and provide opportunities for enhancement of knowledgeand skills of its members and nonmembers through its educational programming. The purpose of itseducational programs is to improve proficiency in the field of cardiovascular ultrasound, which is an importanttool for optimal management of patients with heart disease.To achieve these outcomes, the ASE will: • Direct its programs to cardiologists, pediatric cardiologists, cardiac and vascular sonographers, cardiology trainees, cardiovascular surgeons, anesthesiologists, internists, emergency room physicians, internal medicine trainees, nurses, medical students, and other health professionals. • Assess the educational and training needs of its members in order to design appropriate educational programming. • Provide continuing education opportunities to members and nonmembers throughout the United States and abroad through its primary educational activities: Annual Scientific Sessions; Self-Assessment CD/DVDs; Web-based How-To-Guides; Journal Articles; Guidelines and Standards; Live Didactic Learning Seminars; Core Curriculums; Case Studies; Preceptorships; Train-the-Trainer Slide Sets. • Support and develop course calendars, summits, speakers bureaus and enduring materials, such as CDs and other printed material, that provide educational opportunities to improve proficiency in cardiovascular ultrasound and its application for patient care. • Develop and offer educational experiences for its members. In addition, the ASE will develop joint-and co-sponsorship educational opportunities with organizations that assure and maintain a high standard of quality CME programming.II. DEFINITION OF PLANNED CME PROGRAMS 8
  9. 9. A CME activity can be designated for AMA PRA Category 1 Credits™ if it is provided by an institution ororganization accredited for CME and if the activity meets or exceeds the following criteria:(1) It is based on a perceived or demonstrated educational need and is intended to meet this need;(2) The educational objectives for the activity are stated;(3) The content is appropriate for the specified objectives;(4) The teaching/learning methodologies and techniques are suitable for the objectives and format of the activity;(5) Evaluation mechanisms are defined to assess the quality of the activity and its relevance to the stated needs and objectives;(6) There is documentation of the physicians participation by the sponsoring institution or organization.Once the identified needs are formulated and agreed upon, educational objectives should be determined.Objectives should be written after the need is assessed and the target audience is determined, but before theteaching methods and evaluation techniques are determined. Objectives should be actionable andmeasurable.Participants must evaluate all aspects of CME activities at the close of each program. Please include a copyof the evaluation form you plan to use for your program. Objectives should be listed on the evaluation so thatparticipants may verify whether the objectives were met.ASE encourages all Program Directors to send out a follow-up evaluation within six months of eachCME offering to determine whether identified changes in competence have translated into changes inperformance and changes in the health care of patients.Both the evaluation conducted at the end of the program and the follow-up evaluation can be utilized asNEEDS ASSESSMENT for subsequent CME offerings.Complete written documentation of the processes described above must be kept by the accredited provider(ASE) and made available at the time of an on-site or reverse survey by the accrediting body.III. BROCHURES AND PRINTED MATERIALOnce you receive written approval of your program, you must use the accreditation statement worded exactlyas stated below on all promotional literature. This statement must stand alone and should not be linkedconsecutively with statements of credit of any other organizations. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the American Society of Echocardiography and [insert organization name here]. The American Society of Echocardiography is accredited by the ACCME to provide continuing medical education for physicians. The American Society of Echocardiography designates this educational activity for a maximum of [insert#] AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. 9
  10. 10. ARDMS and CCI recognize ASE’s certificates and have agreed to honor the credit hours toward their registry requirements for sonographers. The American Society of Echocardiography is committed to resolving all conflict of interest issues, and its mandate is to retain only those speakers with financial interests that can be reconciled with the goals and educational integrity of the educational program. Disclosure of faculty and commercial support sponsor relationships, if any, will be made known at the symposium.Under no circumstances should any promotional material and/or programs be distributed indicatingthat the program has been approved for AMA PRA Category 1 Credits™ prior to official writtennotification from ASE. For example, promotional materials may not contain phrases such as "AMAPRA Category 1 Credits™ applied for" or "credit pending" or any other statement relative to AMAPRA Category 1 Credits™ or the awarding thereof.It is required that you submit a copy of all brochures, flyers and other written material for this program to theASE CME Office prior to printing for our review and approval.Registration brochures must contain the following: • ASE Logo must appear on the front and back; • The following verbiage must be included with the logo: Jointly sponsored by the American Society of Echocardiography; • Accreditation and disclosure statement; • Target Audience; • Registration fees (including ASE member discount); • Program overview (including description and learning methods); • Agenda (including registration times, break times, and activities with corresponding faculty); • Faculty (please list name, degrees, affiliation, city and state); • Location and dates (including lodging accommodations and pricing); • Registration form.Brochures and other promotional materials must be approved by ASE prior to distribution. Violationof this procedure may result in termination of the joint sponsorship relationship.IV. FUND MANAGEMENTThe Accreditation Council for Continuing Medical Education (ACCME) states that "the accredited sponsor isresponsible for every aspect of an activity it certifies for credit". ASE is the accredited sponsor and is thedesignated entity responsible for ensuring compliance with ACCME Essentials and Standards. ASE musthave copies of all preliminary and final budgets.Please be sure to include a preliminary budget that includes all anticipated costs and revenues. This shouldinclude registration fees, number of participants, amount of honoraria, any commercial support, and all facilitycosts. Be sure to refer to ASE’s Commercial Support standards, found below, for guidance in funds receivedfrom industry.Please note that ASE assumes no financial obligation to this course; all expenses incurred by thisactivity are the responsibility of the submitting organization.V. LETTER OF AGREEMENT 10
  11. 11. A Letter of Agreement will be sent by ASE to the Program Director outlining the fees to be charged and theresponsibilities of each party for each program certified for CME credit. This Letter of Agreement must be onfile at ASE Headquarters prior to the meeting date.VI. COMMERCIAL SUPPORTWhen a commercial organization provides support for any CME activity it is expected that the commercialcompany is acting as a benefactor. It is proper for a benefactor to choose the general areas with which itdesires to be associated as a benefactor. It is not proper for a benefactor to arrange or control an ASEactivity, such as determining an agenda, choosing a topic or speaker, or to control ASE personnel in theperformance of their functions.Commercial support of CME activities is typically in the form of an educational grant. Such funds are used toassist in the design and implementation of educational opportunities for physicians which stimulate and fosterthe lifelong educational commitment of physicians to improve patient care. Commercial organizations arerequired to comply with the FDAs draft policy and ACCMEs Standards, and faculty are required to complywith the AAMCs Guidelines and AMAs Ethical Opinion in the solicitation and management of such funds.If your program will be collecting commercial support, a Commercial Support Letter of Agreement must becompleted by each industry supporter and be on file with ASE prior to the meeting date. Total compliancewith the ACCME policies on Commercial Support must be demonstrated.ASE may delegate the responsibility for receiving and distributing funds from educational grants to aneducational partner. However, the Letter of Agreement regarding the grant must be between the accreditedprovider and the commercial supporter and the ASE must maintain and be able to produce as documentationa full accounting of the funds.*** If you have any questions concerning commercial support, please contact ASE Headquarters.VII. FACULTY DISCLOSUREHaving an interest in or affiliation with any corporate organization does not prevent participation as a facultymember in a continuing medical education activity. The Accreditation Council for Continuing MedicalEducation (ACCME) Standards for Commercial Support state that "the audience is entitled to know if fundshave been supplied by a commercial source and whether there is any relationship between the speakers andthe company/companies supporting the activity. The audience is also entitled to know if a speaker has asignificant relationship with any commercial company". In other words, the ASE requires disclosure of afinancial interest or other relationship a speaker has with the manufacturer of any product discussed in thepresentation, not only with the supporting company (if any). ASE also requires disclosure of any “off-labelusage” discussed in presentations. ASE requires that a disclosure statement be on file from all speakers at allCME activities.Faculty disclosure is required when a speaker has a significant relationship with any company that sells aproduct or provides a service for which compensation is received, i.e. pharmaceutical companies, medicaldevice manufacturers. Disclosure of any relationships that may be perceived as having potential conflict ofinterest should be requested.It is not acceptable to use product names in a CME activity title. Generic names are acceptable but tradenames should not be used in the activity title unless the activity is intended to be promotional. In order todecrease the changes of promotional intent, it is preferred that trade names are not used during the course ofpresentations. Handouts indicating the trade name and its generic equivalent(s) may be distributed toattendees. 11
  12. 12. When an unlabeled use of a commercial product or an investigational use not yet approved for anypurpose is discussed during an educational activity, ASE requires that the speaker disclose that theproduct is not labeled for the use under discussion or that the product is still investigational.Any relationship between a commercial company and faculty of a CME activity must be disclosed to potentialparticipants PRIOR to the beginning of the activity either in handout material or overhead slides.VIII. RECORDS OF ATTENDANCERecords of attendance at the various sessions of the activity must be maintained and summarized so thatASE can issue evidence of attendance. ASE recommends the use of CME Credit Request forms that allowparticipants to check off the parts of the program they attend to ensure accurate attendance.ASE encourages the use of CME Credit Request forms attached to program evaluation forms. Thisencourages attendees to complete program evaluations.The Program Director will collect and submit the CME forms to ASE Headquarters. The Program Director willalso compile an alphabetized list of all attendees and submit it to ASE Headquarters for Certificate ofAttendance preparation. Certificates of Attendance will be mailed to the Program Director for distribution.IX. JOINT SPONSORSHIPJoint sponsorship is the mutual planning, implementation and evaluation of a CME activity betweenan accredited sponsor (ASE) and a non-accredited organization.No program will be considered for joint sponsorship unless the American Society ofEchocardiography has been involved in the planning of that program.In order to offer joint sponsorship, ASE must:1. Be fully familiar with the activity it might joint sponsor;2. Actively participate in planning the program it joint sponsors;3. Assume full responsibility for the quality of the program it joint sponsors; and4. Have the accreditation statement placed on all program materials.A representative from ASE will be assigned to participate in all phases of planning and implementing theactivity. Designated staff from ASE (or designated on-site monitor) must attend the event and help assurethat it occurs as planned and in full compliance with the Essentials.Conference evaluations should be conducted using ASEs standard form plus any additional form offered bythe joint sponsor and summarized by the joint sponsor and prepared for use by the planning committee forsubsequent iterations of the activity.Records of attendance should be maintained and summarized (CME Request Forms) so that ASE can issueevidence of attendance.Complete written documentation of all the processes described above for all joint sponsored events must bekept by the accredited sponsor and made available at the time of an on-site or reverse survey by theaccrediting body.All Commercial Support Letters of Agreement and Faculty Disclosure Forms must be filled out and be on filewith ASE prior to the meeting date. Total compliance with ASE CME Policies and ACCME Policies must bedemonstrated. 12
  13. 13. All costs not covered by registration fees, tuition or course income must be defrayed by the Joint Sponsor.A Letter of Agreement (CME Joint Sponsorship/Designation Policy) will be sent by ASE to the Joint Sponsoroutlining the responsibilities of the joint sponsor and ASE for each program certified for CME credit. ThisLetter of Agreement (CME Joint Sponsorship/ Designation Policy) must be on file with ASE prior to themeeting date.Program PlanningThe Program Director or Program Coordinator must provide the complete application (typed) and otherpaperwork, i.e. documentation of needs assessment, preliminary budget, preliminary program and applicationfee to ASE Headquarters as soon as possible following the completion of the planning session. Applicationsnot accompanied by the application fee will be considered incomplete and will not be processed until theapplication fee is received. If the application fee cannot be submitted with the application, other arrangementsshould be discussed with ASE CME staff.Applications for joint sponsorship are rigorously evaluated by ASE for full compliance with the Essentials.Applications for activities that are already planned are NOT approved. Only if full compliance to the Essentialsis evident is the application passed on to the ACCME/CME Committee for review.If your program will receive commercial support, the following documents must be returned to ASEHeadquarters:1. Disclosure Statement signed by each speaker.2. Commercial Support Letter of Agreement.If the program is accepted for joint sponsorship, you will receive written verification of approval. If the programis denied, you will receive a written communication stating denial and reason for denial.All jointly sponsored programs are required to have an ASE representative on site to monitorprogram compliance with ACCME Essentials at a charge of $200.00 per day. In addition, the jointsponsor is responsible for the cost associated with travel and lodging expenses for the CME staff member. Iftravel to the program includes air travel, the joint sponsor is responsible for arranging appropriatetransportation from the airport to the program site.THESE CHARGES ARE SUBJECT TO CHANGE AT ANY TIME.A Letter of Agreement will be sent to the Program Director outlining the fees to be charged and theresponsibilities of both the joint sponsor and ASE for each program certified for CME credit. The Letter ofAgreement must be signed by the Program Director and returned to ASE prior to the date of theactivity.Program Follow-up for Jointly Sponsored ActivitiesWithin 30 days following the CME activity:A. The Sponsor (ASE) will: a. Prepare Certificates of Attendance for all attendees who have completed and returned their CME Credit Request Forms. These certificates will be mailed to the Program Director for distribution to the participants. b. Supply copies of the Corporate Support Agreement to each source of commercial support upon request.B. The Program Director will: 13
  14. 14. a. Submit final brochures and other promotional materials, such as flyers, pamphlets, announcements, etc. to ASE Headquarters. b. Submit Corporate Support Agreements and copies of checks for any programs receiving commercial support. c. Submit Recording and Administrative Fees to ASE. d. Submit a complete accounting of the CME activity to ASE Headquarters. PRE-ACTIVITY REQUIREMENTS • The completed ASE joint sponsorship application, including attachments, should be submitted to the ASE CME Office at least six months prior to distribution of promotional materials. • At least 10 business days are required for review of a submitted application. This estimate of time may change due to application volume. • Under no circumstances may the ASE name and/or logo be used to promote an educational activity prior to receipt of written approval of ASE joint sponsorship. • Upon receipt of written approval of ASE joint sponsorship, a signed letter of agreement should be returned to the ASE CME Office no later than 15 business days after receipt. • All printed materials must be reviewed and approved by the ASE CME Office prior to printing and distribution. • At least 30 days prior to the start of the activity, the course planner should provide ASE with a mailing address for shipment of ASE’s educational materials, which will be made available to attendees onsite at the program. • At least 3 weeks prior to the start of the activity, CVs and up-to-date disclosure information for all faculty must be on file with ASE. • At least 30 days prior to the start of the activity, a copy of all signed commercial support letters of agreement should be on file with ASE POST-ACTIVITY REQUIREMENTSASE requires that final drafts of the following items be kept on file in our office for all ASE sponsorededucational activities: • Five (5) copies of all promotional materials, including save-the-date cards, registration brochures, etc. • Two (2) copies of all handouts and/or syllabus materials provided to attendees onsite. • One (1) electronic copy of the final faculty and attendee list, including name, address, phone, fax and email contact information. • One (1) electronic copy of the final summary of the attendee program and faculty evaluation. • One (1) electronic copy of the final summary of program income and expenses, and copies of all commercial support grant checks, etc. • One (1) copy of all CME request formsCopies of the above items should be on file in the ASE office within two months of the completion of theeducational activity. 14
  15. 15. FEE STRUCTURENON-REFUNDABLE APPLICATION FEEMade payable to the ASE Foundation, tax ID #43-1972597.Joint Sponsored Program $5,500.00 Monthly Calendar Listing in JASE Included in Application Fee for Approved Programs Online Listing at www.asecho.org Included in Application Fee for Approved Programs Monthly Listing in the ASE Newsletter Included in Application Fee for Approved Programs ASE Membership List Included in Application Fee for Approved (One time use only, mailing must be approved Programs by ASE)ADMINISTRATIVE FEESPer CME Certificate Printed $30.00Monitoring Fee $200.00/per day plus travel expenses(ASE reserves the right to monitorany program to ensure compliancewith ACCME Essentials and Standards andASE Policies)OPTIONAL PURCHASESPlease contact the ASE CME staff for additional information on these opportunities.Online Registration $500.00 APPLICATION CHECKLISTThis application contains the following, necessary materials: Completed Application Planning Budget Needs Assessment Documentation Program Agenda and Preliminary Registration Brochure Attendee Program and Faculty Evaluation Chair/Co-Chairs CVs and disclosure Information 15
  16. 16. Non-refundable application fee of $5,500 AGREEMENTI hereby certify that the above statements are correct and complete. I agree to display and makeavailable onsite to attendees ASE educational materials, which ASE will provide. If the educationalprogram includes industry exhibits, I agree to offer ASE complimentary space if requested. Iunderstand that ASE does not certify that attendance at an ASE course guarantees competence orproficiency in the performance and/or interpretation of cardiovascular ultrasound. I understand andagree that if this course is approved for ASE joint sponsorship, ASE assumes no financial obligationto this course; all expenses incurred by this activity are the responsibility of myself and/or thesponsoring organization.I acknowledge that the joint sponsorship application fee is non-refundable and submission of thisapplication does not imply course sponsorship by ASE; the sponsorship decision is at the solediscretion of the American Society of Echocardiography. X Signature and Date If you have any questions regarding this application, please contact: Cheryl Williams CME Manager, ASE 2100 Gateway Centre Blvd., Ste. 310 Morrisville, NC 27560 Direct Line: 1-919-297-7160 Fax: 1-919-882-9900 E-mail: cwilliams@asecho.org 16

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