(Course # )
(Assigned by CME Office)
UNIVERSITY OF OKLAHOMA COLLEGE OF MEDICINE
IRWIN H. BROWN OFFICE OF CONTINUING MEDICA...
E. Commercial Support. Will this activity involve commercial support from manufacturers, pharmaceutical companies, etc. fo...
Irwin H. Brown Office of Continuing Medical Education
College of Medicine
TRACKING SHEET FOR CME COURSE ESSENTIALS
(PLEASE...
(This list is not exhaustive...please use it as a discussion tool and memory crutch. Feel free to add
to and enhance it in...
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(Course # )

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(Course # )

  1. 1. (Course # ) (Assigned by CME Office) UNIVERSITY OF OKLAHOMA COLLEGE OF MEDICINE IRWIN H. BROWN OFFICE OF CONTINUING MEDICAL EDUCATION REGULARLY SCHEDULED CONFERENCE (RSC) APPLICATION (Fiscal Year ____________) (Grand Rounds, Staff Conferences, Teaching Conferences, Etc.)  OU College of Medicine or  Joint Sponsorship Program (Outside the College of Medicine) This application is designed to meet the requirements of the Accreditation Council for Continuing Medical Education in sponsoring OU COLLEGE of MEDICINE and JOINT SPONSORSHIP (Outside the College of Medicine) educational activities where CME Category 1 credit is desired. Please call (405) 271-2350 if you have any questions regarding regularly scheduled conferences or about the completion of this application. Directions: If you plan to complete the application by hand, please print all documents first. To complete the application on the computer, delete the lines before typing to keep the lines from wrapping, thus distorting the application format. When completed, print documents and send or fax them to the CME Office (405) 271-3087. Name: Contact Person/Secretary: (Course/Activity Director) Phone: ( ) ____________ Fax: ( ) Phone: (___)____________ Fax: (___) Campus Address: Email: Address: Campus Address: Email: OU Department: Organization Name: Street Address: A. Identification of Activity Name of Regularly Scheduled Conference: Activity location: Bldg. Name/Room #: Street Address of Activity: Activity Schedule: (Every Wednesday at Noon, July thru June; etc.) ______________________________________________________ (If the Schedule changes during the year, please notify the CME office.) B. Activity Need and Design 1. What information and/or data did you use to determine the need for this activity by your target audience? (Check all that apply) DOCUMENTATION IS VERY IMPORTANT. To show how need was determined, you must enclose copies of committee minutes, physician survey results, research data, previous participant evaluations, etc. ___ Medical audit ___ Participant evaluation feedback ___ Recent research ___ New technique/material ___ Physician survey ___ Review/update ___ Other (specify) 2. Please enclose a completed TRACKING SHEET showing the following: • Needs addressed by the course • Activity objectives on what the participant should know or be able to do upon completion of this activity • Presentation methods (See reverse side of tracking sheet) • Evaluation • Summary of last year’s activity evaluation, if applicable C. Activity Promotion 1. How will participation for your activity be solicited? ___________________________________________________ Please remember that the ACCME accreditation statement, one objective, the OU ADA statement and commercial support, if applicable, must be listed on ALL flyers, e-mails, and promotional materials. D. Evaluation. Do you plan to use the CME Evaluation Forms? YES___ NO___ If no, please enclose a copy of the evaluation form to be used. Sample evaluation forms are included in your application packet and are available on-line on our web page: http://cme.ouhsc.edu. Page 2 Regularly Scheduled Conference Application /mnt/temp/unoconv/20150125230519/course4052.doc
  2. 2. E. Commercial Support. Will this activity involve commercial support from manufacturers, pharmaceutical companies, etc. for speakers, lunches, etc., at any time during the year? YES___ NO___ The CME Office must be notified of ALL commercial support obtained during the year. This includes commercial supporters paying for catering. Commercial Supporters cannot directly pay for anything. Failure to notify the CME office could jeopardize our granting credit for your Activity. See the instruction memorandum in the packet for details regarding the required paperwork. Your department/organization is responsible for the distribution of the paperwork when commercial support is involved. The educational grant check must be made payable to OUHSC-CME and the CME office must reimburse the speaker's expenses and pay the honoraria. F. Speaker Disclosure. A Speaker Disclosure Form (SDF) must be completed by every speaker for each activity two weeks before his or her presentation and the content of these completed forms must be conveyed to your participants. (Information from the Speaker Disclosure Form must be disclosed to the audience prior to the presentation, even if there is nothing to disclose). How will you inform the audience of the information from the Speaker Disclosure Forms?: (Submit to the CME office the handout, sign, slides or overhead copy for documentation purposes). ____ Will put on printed materials ____ Will post via a sign, slide or overhead ____ Other (Specify) G. Conference Planning Committee. Please list names and titles (use extra sheet if necessary). H. Administrative Fee and CME Course Certificates. An annual application fee of $300 for College of Medicine departments with commercial support and Free if no commercial support is involved. However, if commercial support is received after the application has been submitted, the department will be billed $300. The fee for all other non-OU College of Medicine departments/organizations (Joint Sponsorships) is $600 for approving the application and the recording and maintenance of CME records. Each July you must report to the CME Office a listing of the topics and speakers, a year-end survey, the Participant Information reporting form to include name, title, address, phone, fax, email and the total number of credits for each physician/participant. After the year-end reporting is complete, a course certificate will be created for each participant, indicating the number of credits earned for the year. The certificates will be given to the course contact person for distribution to the physicians/participants.Applications for credit will not be approved until reporting is complete. The annual fee should accompany this application either in the form of a check made payable to OUHSC-CME or a copy of the transfer. If off campus, our Tax ID is 73 601 7987. OUHSC departments must pay by transfer only. To transfer you must reference your course number on the spreadsheet in the description & reference field and send a copy of the transfer paperwork to the CME department. Our chartfield spread information is: Fund: MISCA, Org: COM 015, Program: 00014, Sub Class: 00000, Project Grant: N/A, GL Account Codes: + 111701, - 950900. (See Program Fee Descriptions on the CME web page). Please submit with your application a check made out to OUHSC-CME or a copy of your transfer request. APPLICATION DEADLINE: The regularly scheduled conference year is from July 1 - June 30. To receive credit for the full year, your application must be submitted prior to your first activity. If additional information is required before your activity can be approved, items must be returned within 30 days, or credit for your activity will begin on the date the application is approved. A complete application must include the Tracking Sheet, proposed curriculum plan and fee payment. Annual Fee Included ___ Yes ___ No ___ N/A Paid by ____ Check or ____ Transfer (We need a copy of your transfer paperwork & please reference your course number and title on the transfer spreadsheet) ________________________________ ___________ _________________________________________ Signature of Program Director Date Signature of Department Head or Designee Date This program is approved for credits in Category 1 of the Physicians' Recognition Award of the AMA. __________________ Assistant Dean for Continuing Medical Education Date Return completed forms & all documentation to: The University of Oklahoma Health Sciences Center Irwin H. Brown Office of Continuing Medical Education (CME) P.O. Box 26901, ROB 202 Oklahoma City, OK 73190 (405) 271-2350 /mnt/temp/unoconv/20150125230519/course4052.doc
  3. 3. Irwin H. Brown Office of Continuing Medical Education College of Medicine TRACKING SHEET FOR CME COURSE ESSENTIALS (PLEASE RETURN TO CME OFFICE WITH APPLICATION) Name of Program Needs Addressed by This Program How Were Needs Determined Objectives Upon completion of this activity, the participant should be able to: Presentation Methods Evaluation (How will you determine if objectives were accomplished?) Submit feedback from past evaluations, if applicable. Feedback From Past Evaluations into This Course (If Applicable) PRESENTATION METHODS The following are possible methods for presenting information or attempting to change behavior. /mnt/temp/unoconv/20150125230519/course4052.doc
  4. 4. (This list is not exhaustive...please use it as a discussion tool and memory crutch. Feel free to add to and enhance it in any way. Also, please share your enhancements with us at the CME office.) Bedside patient contact ("mini-residency") -- supervised care by the student Case presentations followed by lecture or discussion Discussion -- panel -- audience Distance learning techniques using TV, FAX, INTERNET, other imaging, broadcast of pre-recorded content, duplex TV or audio hookup for discussion ("Videoconferencing" or "Teleconferencing"); uses fiber optics network, TV satellite or phone hookup with "compression" techniques Follow specimen through the lab analysis process -- learn the methods Initial listing of participants' questions followed by speaker's extemporaneous answering of the questions Homework exercise prior to presentation Lab/workshop with hands-on experience Lecture Patient simulation or real taped encounters Reading assignment followed by lecture/discussion Role-playing Self-paced book or other package with post-test for credit Short lecture followed by equal amount of audience questions Simulation of procedure -- using experimental animals -- using mannequins/models Slides, animation or computer-generated graphics Teleconferencing or Videoconferencing (see Distance learning techniques) Video presentation or movie -- alone or as discussion trigger Videodisk programmed learning -- multiple-branching case simulations NOTE:Please consider that methods for transferring information will likely differ from those for imparting skills, teaching procedures or changing attitudes. /mnt/temp/unoconv/20150125230519/course4052.doc

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