Formal Planning Guide and Application Form
The University of Arkansas for Medical Sciences College of Medicine is accredited by the Accreditation Council
for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The mission of the UAMS College of Medicine Continuing Medical Education (CME) Program is to assist
physicians in their pursuit of life-long learning for the purpose of providing high quality health care. This is
accomplished by offering educational opportunities that support physicians' improvement in their competence
in patient care, medical knowledge, practice-based learning and improvement, interpersonal and
communication skills, professionalism, and systems-based practice.
Means and Purpose
The University of Arkansas for Medical Sciences (UAMS) is the sole academic medical center in the state of
Arkansas. It consists of five colleges and a graduate school sharing a common mission: to teach, to heal, to
search, and to serve the healthcare needs of the people of Arkansas. The College of Medicine's CME
Program is central to this broad mission. The major purpose of the CME Program is dissemination of state-of-
the-art, evidence-based education that will allow practicing physicians opportunities to maintain and enhance
their knowledge and skills, and in the process, reaffirm their professional commitment to the provision of
excellent health care.
The content of CME activities produced by the UAMS College of Medicine (COM) is determined and initiated
by the College of Medicine faculty and through joint sponsor relationships with other organizations including
state health agencies, community and regional hospitals, and medical professional societies whose own
missions are aligned with that of the UAMS College of Medicine. CME activities are developed based on needs
assessment data to ensure that activities present current, state-of-the-art, evidence-based information in order
to improve physician competence, performance and/or patient outcomes in Arkansas.
Educational activities are designed for practicing physicians whose work crosses the continuum of primary
care, specialty care, and tertiary care. Other health care professionals are welcomed to activities appropriate
to their needs for education at the physician level. These activities draw participants from local, regional,
national and international geographic areas.
Types of Activities Provided
The CME Program offers a broad spectrum of educational activities using a range of instructional methods
including didactic lectures, symposia, demonstrations, interactive workshops, case-based conferences,
interactive video conferences, and self-directed learning materials (e.g., enduring materials such as Internet
activities, instructional videotapes, CDs, and printed documents). The UAMS College of Medicine CME
Program is committed to exploring new initiatives and opportunities in education to enhance the overall
program and encourage development of Performance Improvement and other innovative approaches to
physician CME learning activities.
Expected Results of the Program
The CME activities approved by the Office CME will contribute to improved physician competence,
performance, and enhanced health care outcomes for Arkansans.
Formal CME Activity
A Formal CME activity is considered to be one that is presented as a live conference or lecture.
The purpose of this planning guide and application form is to document compliance with the
requirements of the Accreditation Council for Continuing Medical Education (ACCME), the national
organization that accredits the UAMS College of Medicine Office of Continuing Medical Education to
provide CME for physicians. This interactive planning process is designed to assist you in
planning a CME activity that meets the expectations of the ACCME and the OCME.
The checklist and timeline will help you know when to submit the necessary forms and documentation
for your event. You will need to use the <TAB> key to advance from field to field when completing this
You will find within the form, explanations, examples, check boxes and text boxes in which to type.
You will see the icon, , whenever documentation is required upon submission of the application.
When you have completed the form, save, print, and submit it, along with the necessary
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If you have questions or need assistance, please feel free to contact us by calling 501-661-7962,
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CHECKLIST AND TIMELINE
Pre-activity materials - Submit with the application for preliminary approval
Application/Planning Document 4-6 months before the activity
Joint Sponsorship Agreement, if applicable 4-6 months before the activity
Documentation of Planning (minutes, notes, etc.) 4-6 months before the activity
Planning Committee Disclosure Forms 4-6 months before the activity
Needs Assessment Documentation 4-6 months before the activity
Preliminary agenda (proposed topics, speakers, timeline) 4-6 months before the activity
Preliminary Budget 4-6 months before the activity
Submit before the activity for final approval (if not included with initial application submission)
Draft of faculty invitation letter (see faculty letter template) 2-4 Months before the activity
List of faculty with credentials and topics 2-4 Months before the activity
Faculty CVs (required for non-UAMS College of Medicine Faculty) 2-4 Months before the activity
Final Agenda with speakers/topics/time slots 2-4 Month before the activity
Draft of brochure, save the date and/or other announcements A draft
copy of all printed materials including but not limited to: save the
date, brochure, syllabus, evaluation, must be reviewed and
approved by OCME prior to printing.
2-4 Months before the activity
Proposed evaluation tool, if not using OCME standard forms 2-4 Months before the activity
Faculty disclosure forms All faculty and planning committee members
must complete and appropriately sign a Disclosure Form prior to
the activity. Conflicts of Interest (COI) must be resolved by the
1 Month before the activity
Written disclosure method Disclosure of financial relationships must
be communicated to the participants prior to the activity. It is
required that you submit your slides, signs, or whatever written
method you plan to use for disclosure to the OCME for approval
prior to the event.
1 Month before the activity
Commercial Support Agreement (LOAs) All educational grants must
be documented by an appropriately signed LOA for commercial
1 Month before the activity
Proof of payment for CME approval 1 Month before the activity
Post-activity materials - Submit within 30 days of the activity’s completion
CME Formal Activity Closing Report - (Form
available on the OCME Website)
Participant evaluation summary including
Final budget - Must include a breakdown of All
income sources and all expenditures.
Attendee roster or excel data file with/name,
degree, address, last 4-digits SSN & email
Final syllabus/handout (1 copy)
Verification of disclosure - Must send a copy of 1)
slides, handouts, and 2) verification of
disclosure attestation statement
Final brochure (5 copies)
Verification of acknowledgement of commercial
support, if applicable
Copy of certificate (For MDs and Non-MDs)
APPLICATION FOR SPONSORSHIP OF
A FORMAL CME CONFERENCE
START DATE END DATE
START TIME END TIME
(Hotel or other, etc.)
SPONSORSHIP AND COURSE MANAGEMENT
Must be a UAMS
College of Medicine
Department or AHEC
UAMS College of Medicine, Department of:
Area Health Education Center (AHEC), Location:
are organizations or
entities external to
UAMS College of
Medicine who are not
accredited by the
Yes…..If yes, complete the Joint Sponsorship Agreement and include it with this
application. List the organization(s) or outside entities involved in planning this
ORGANIZATION CONTACT NAME PHONE #
Is a member of the UAMS College of Medicine Faculty involved in the planning and/or
organization of this activity?
YES NO If yes, Faculty member’s name:
ACTIVITY MANAGEMENT: Who will have primary responsibility for managing this CME activity?
UAMS College of Medicine department/AHEC Office, please specify:
Joint Sponsor/Educational Partner, please specify:
Course Director: Date:
Chairman/Division Head/CEO: Date:
TYPE OF ACTIVITY
Formal Activity (symposium, course, conference)
Short Activity or lecture 1-2 hrs in length.
Live interactive/compressed video conference
Live web cast
Series (same content
presented multiple times)
(Not considered as an
Regularly scheduled series)
NEW REQUEST ANNUAL ACTIVITY
DESIRED CREDITS AMA Category 1
COMMERCIAL SUPPORT – INDEPENDENCE OF THE PLANNING PROCESS
The ACCME requires the following decisions in planning a CME activity be made free of control by a
commercial interest (refer to and policies). These decisions include:
1) Identification of needs
2) Determination of objectives
3) Selection and/or presentation of content
4) Selection of personnel and organizations who would
be in a position to control the content
5) Selection of educational methodology
6) Evaluation of the activity
1. PLANNING PROCESS
emails, or other
documentation of the
Describe the planning process for the content (not the meeting logistics).
Check all that apply.
Who is the target audience?
Physicians: Specialties (specify):
Nurses Pharmacists Dietitians Social Workers
Health care administrators Other (specify):
Local State Regional National International
Estimated Attendance: Physicians Other
Needs Assessment is defined as "any systematic approach to collecting and analyzing information about the
educational needs of individuals or organizations." Educational needs may be perceived, desired or thought to
be important. The needs assessment data is the basis for developing learning objectives for a CME activity.
A needs assessment is a tool to identify a gap, the difference or distance between what is occurring in practice
and what is expected (the desired outcome), or, the difference between what is and what should be.
For more information about conducting a needs assessment refer to the Needs Assessment Guidelines and
the Types of Needs Assessment Data Sources guide.
3. NEEDS ASSESSMENT
MUST be included with the
Check all methods that
For more information
about needs assessment
refer to the following:
and the Types of Needs
Watch the ACCME Video
about needs assessment
compliant data (2 min.):
A needs assessment that meets ACCME compliance must go beyond
identifying the perceived need of a professional performance gap. Additional
data that is evidence-based must also be provided in support of the identified
Needs perceived by clinical experts
Clinical expert opinion (activity faculty, planning committee members, department
chair, etc.) Please list the names of those giving expert opinion and their credentials:
Needs perceived by targeted participants (provide summary for each method
Needs Assessment survey of target audience
Previous evaluation summary* (Required for renewal applications.)
Focus group discussion/interviews
Requests by affiliated institutions
Requests from other physicians
Other, please specify
Clinical expert opinion and/or participant needs are perceptions that must be
supported by at least one evidence-based data source for each identified need.
Choose at the minimum one source from the categories below for each
performance gap this CME activity will address:
Evidence-based information (provide copy of summary or source)
Peer-reviewed literature (provide summary)
Research findings, please specify
Medical School requirements, please specify
Government laws/regulations, please specify
National guidelines (NIH, NCI, AHRQ, etc.) please specify
Specialty society guidelines, please specify
Other, please specify
Observed Needs (provide summary or copy of data for each of the selected)
Adverse drug events
Database analysis (e.g., RX changes, diagnosis trends, etc.)
Hospital/Clinic Quality Assurance data
Pharmacy & Therapeutic or Quality Improvement data/guidelines
Morbidity & Mortality data
Other clinical observations
Other, please specify
Environmental Needs (provide a copy of the standard/law/etc.)
Joint Commission Standards/Core Measures
Lay Press (specify):
Other societal trends (specify):
4. After analyzing the
data obtained from the
sources on the
previous page, please
process of analyzing
the data and explain
Now, outline the professional performance gap(s) identified during the needs assessment. Explain the
desired result of the CME activity for reducing or removing the identified gap. In other words, what will
the learners be able to apply in their practice based on the knowledge and implementation strategies
addressed in this activity? Add more lines or provide information on a separate page, if necessary.
Identified GAP/Learners’ Needs
What was identified as missing or
deficient (the professional
performance gap) in what the
targeted learners know and/or can
do in their healthcare practice or in
their care of patients?
After the CME activity, what
would indicate a reduction or
elimination of the gap?
Where do you need to focus
the content? The objectives
and instructional methods will
be determined by the content
focus of the CME activity.
Knowledge (do not know)
Competence (know but
unable to apply if needed)
Performance (able to do)
(demonstrated changes in
patient outcome indicators)
Physician Competencies and Attributes
The Maintenance of Certification (MOC) competencies designated by the American Board of Medical Specialties
(ABMS) and Accreditation Council of Graduate Medical Education (ACGME), and the Attributes identified by the
Institute of Medicine (IOM) are national goals for physicians and, when possible, should be addressed in CME
Patient Care or Patient-Centered Care: identify, respect, and care about patients’ differences, values, preferences, and
expressed needs; listen to, clearly inform, communicate with, and educate patients; share decision making and
management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a
focus on population health.
Medical Knowledge: established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social behavioral)
sciences and the application of this knowledge to patient care.
Practice-Based Learning and Improvement: involves investigation and evaluation of their own patient care, appraisal and
assimilation of scientific evidence, and improvements in patient care.
Interpersonal and Communication Skills: that result in effective information exchange and teaming with patients, their
families and other health professionals.
Professionalism: commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a
diverse patient population.
System-Based Practice: actions that demonstrate an awareness of and responsiveness to the larger context and system of
health care and the ability to effectively call on system resources to provide care that is of optimal value.
Interdisciplinary Teams: cooperate, collaborate, communicate and integrate care teams to ensure that care is continuous and
Quality Improvement: identify errors and hazards in care; understand and implement basic safety design principles such as
standardization and implications; continually understand and measure quality of care in terms of structure, process and
outcomes in needs; and design and test interventions to change processes and systems of care, with the objective of
Utilize Informatics: communicate, manage knowledge, mitigate error, and support decisions making using information
Employ evidence-based practice: integrate best research with clinical expertise and patient values for optimum care,
and participate in learning and research activities to the extent feasible.
Indicate physician competencies and attributes that will be addressed in
the curriculum of this CME Activity. Please check all that apply:
Patient/Clinical care Patient-centered care
Medical knowledge Interdisciplinary team work
Practice-based improvement Evidence-based practice
Communication skills Quality improvement practices
Professionalism Utilization of informatics
Now, review your identified professional performance gaps, the desired results (what will indicate that
the gaps have been reduced or eliminated), and what content focus (knowledge, competence,
performance and/or patient outcomes) that the CME activity is designed to address. Your objectives
should be based on the identified professional practice gaps you identified from your needs assessment.
Terminology for educational objectives usually begins with, "Following this activity, the participant should be
able to . . ." followed by phrases that communicate a measurable performance capability, by the participant.
Think of performance as the action of doing something. Whenever possible, think in terms of improving patient
Use verbs that convey doing such as: describe, analyze, discuss, compare, differentiate, examine, formulate,
propose, evaluate, assess, measure, select, and choose when writing your objectives. Write objectives that are
parallel to the level of learning you are attempting to accomplish. Knowledge, competence, performance, and
patient outcomes objectives require different objectives.
Avoid verbs that are not easily measured such as understand, appreciate, and know.
For more information about writing measurable, performance-based objectives refer to Guidelines for Writing
The audience must be
about the activity’s
goals and/or objectives
before activity occurs.
For more information
about notifying the
Based on what you hope to accomplish, list three or four objectives that
reflect what you would like for the participants to be able to do as a result
of participation in this CME activity. These are objectives for the entire
activity. If there is not enough room here, please use a separate page and
submit as an attachment.
7. EDUCATIONAL FORMAT
Consider what will be the
most effective method(s) for
achieving your objectives to
eliminate or reduce the
What instructional methods will be used? (Check all that apply)
Live lecture presentation (knowledge)
Panel discussions (knowledge)
Case studies (competence)
Interactive workshops (competence)
Interactive telecommunication (knowledge, competence)
Live demonstration of procedure (competence)
Video demonstration of procedure (competence)
Skills workshop (competence, performance)
Individual study assignment (knowledge, competence)
Other, please describe.
8. FACULTY SELECTION
Please tell us why and how the speakers were selected and who was
involved in the decision to select the speakers?
9. ACTIVITY AGENDA
Documentation Attach a copy of
A copy of the proposed schedule is attached. Yes No
It must include specific time schedule, speakers, and topics. Approval
cannot be granted until the final agenda is received.
If no, please explain.
DISCLOSURE OF FINANCIAL RELATIONSHIPS
REQUIRED BY THE ACCME Refer to the Policy for Disclosure of Financial Relationships and Resolution of
Conflicts of Interest
UAMS CME DISCLOSURE POLICY It is the policy of the University of Arkansas for Medical Sciences (UAMS)
College of Medicine to ensure balance, independence, objectivity, and scientific rigor in all sponsored 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 they have with any commercial interest(s). These individuals include
course/activity directors, planning committee members, staff, teachers, or authors of CME. 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 MUST BE disqualified from participation in the development,
management, presentation, or evaluation of the CME activity.
• The “Disclosure and Attestation Statement” (disclosure form) is the mechanism used by the OCME to gather
information about relevant financial relationships with commercial interests.
• This form must be completed by EVERYONE who has the opportunity to influence the content of the CME
activity, including the course director, CME Associate, planning committee members, speakers, authors,
• Individuals refusing to disclose MUST NOT be allowed to participate in the CME activity. Failure to return a
disclosure form is equal to refusing to disclose.
• Conflicts of Interest (COI) must be resolved BEFORE the activity occurs, preferably during the early
• It is the responsibility of the Course Director to make certain that all of the disclosure forms are collected,
reviewed for relevant financial relationships with commercial interests and all conflicts of interest resolved.
Disclosure forms and documentation of how relevant financial relationships were explored and any conflicts
of interest were resolved must be submitted to the OCME well before the activity begins.
Documentation Attach copies of
letters, memos, emails, etc.
How were planners and faculty informed about disclosure?
11. DISCLOSURE FORMS and
RESOLUTION OF CONFLICTS
OF INTEREST (COI)
Refer to the Disclosure Form
Faculty disclosure forms must be
submitted with this application or
prior to the activity, see checklist
and timeline below.
Yes, disclosure forms are attached for everyone who has the
opportunity to influence the content of the CME activity.
No, all disclosure forms are not attached.
All planners must complete UAMS
College of Medicine’s Disclosure and
Documentation These disclosure
forms MUST be attached to this
Refer to UAMS Policy on Disclosure
and Resolution of Conflicts of Interest
Attach a separate page if
there is not enough room
List all individuals who are involved in planning.
Name Affiliation Disclosure
ACCME Requires Documentation. Complete the form below OR provide the information on a separate
sheet as an attachment. 1) Please attach a copy of a curriculum vitae or biological sketch for each
course faculty (speaker/moderator/author) who is not on the UAMS College of Medicine faculty. (Attach
separate sheet if necessary.) 2) Disclosure form for each speaker/moderator/author 3) Review all
disclosures of relevant financial relationships with commercial interests and resolve any conflicts
of interest. Document how any conflicts of interest were resolved and submit that information to the
OCME prior to the activity.
Speaker/Moderator/Author Academic/Professional Titles Institution or
12. PROVIDE DISCLOSURE TO
A copy of the written method AND a
verification of disclosure attestation
form will be required to be submitted
with closing report after CME event.
How will the audience be given disclosure information gathered
from the above planners, faculty, speakers, etc.?
Written (preferred): Handouts Slides Other,
Verbal by: Speaker Moderator
13. COMMERCIAL SUPPORT
Required by the ACCME, if
there is commercial support
Refer to the Standards for
1) Acknowledgement - The
audience must be informed about
2) Letters of Agreement for
Commercial Support (LOA) must
be executed for ALL educational
grants. The LOA is between the
accredited provider (UAMS COM)
and the company. They must be
signed by both the company’s
representative and the accredited
CME provider’s representative.
3) The LOAs should be submitted
prior to the activity if possible
and if not received prior to the
activity, they must be included in
the closing report.
4) An exhibitor form must be
completed for each exhibitor.
Will this activity receive support from Educational grants?
Will there be exhibits?
If yes, how will commercial support for this activity be
acknowledged to the participants?
Other, please describe.
Management of Commercial Support The Course Director and CME
Associate have read the ACCME’s Standards for Commercial
Support of CME and understand the guidelines for
management of commercial funds.
A complete accounting of the commercial support must be submitted
with the closing report at the conclusion of the activity.
14. MARKETING AND ADVERTISING
The ACCME requires certain
information be included on
• target audience
• purpose and/or objectives,
• accreditation statement
• AMA PRA Category 1 Credit™
The OCME must approve
promotional materials before they are
Refer to Guidelines for Brochures and
How will notification of this educational activity be distributed to
the participants prior to the activity?
Website: URL site:
A copy of the promotional material is attached.
A copy of the promotional material will be sent later.
There are some important areas that need to be addressed by the evaluation of the program.
Participants should have the opportunity to:
1. rate the overall quality of activity
2. assess the extent that the objectives were met
3. rate the extent that their professional effectiveness will be enhanced
4. incorporate an outcomes question
5. assess if bias or the appearance of bias existed in the instructional process
6. rate the quality of the faculty
7. confirm that disclosures were made known to the audience at the beginning of the activity
8. confirm that commercial support was acknowledged, if applicable
9. rate the learner satisfaction
ACCME Requirement: (see essential area 3)
All CME activities MUST be evaluated to determine the effectiveness of meeting the identified
Plan an evaluation method that corresponds with the outcome. For example, if you are
planning to have performance as an outcome, then how are you going to measure that the learner
can now perform the task or skill? If you plan to have an outcome to change patient outcomes, what
is your evaluation plan for determining the change in patient outcomes?
There must be a plan to measure this change.
Standard evaluation forms are posted on the OCME Website:
Overall Evaluation Individual Speaker
ACCME Requirement Please attach a copy of the form you plan to use or explanation of evaluation method.
A copy of the summarized results MUST be submitted with the final “Activity Closing Report”.
What method(s) will be used to assess what the participants have learned as a result of attending this
educational activity? Please select all that apply:
Post-activity evaluation (measures perceptions of knowledge acquisition and satisfaction)
OCME standard post-evaluation form
Other evaluation form (attach a copy, must be approved in advance).
Pre-Post test (measures immediate learning) (attach a copy).
Learning Contract (commitment to change) questions (attach a copy)
Audience Response (identifies if learners understand content and provides learning reinforcement)
Focus Groups (qualitative measurement to explore more in-depth information)
Post-conference follow-up (3-6 months post-conference to measure for performance change) (attach a copy of follow-
Or, describe alternative evaluation method
Requirement Attach a
preliminary budget (rough
estimates are acceptable)
including all projected
revenue and expenses.
A final income and expense
report is required with the
activity closing report.
Refer to the budget
How will activity expenses be paid? (check all that apply)
Internal department funds
Participant registration fees
State or Federal Grant
Attach a check or
copy of IDT or other
Please include payment with the application.
Method of payment:
IDT (include a copy or other proof of transaction) Please indicate the
activity title in the text fields to assure proper posting.
Credit to: 118-600001-1006376
Debit to: xxx-631600-xxxxxxx
If payment is not included, please explain.