ࡱ> fiabcde gbjbj u#u$$ggggg$P,4Ƨ;,,,,X/N//zg/.^X///gg,, 444/^g,g,4/44Fѕ,x0A00T0Ƨ50LgQ//4/////x2///Ƨ/////////////$ -:   Office of Continuing Medical Education Certification Request for Sponsorship of a WFBH/WFSM Regularly Scheduled Series (RSS) and AMA PRA Category 1 Credit(s)TM Certification Request Submission Flowchart  Introduction The Wake Forest University Health Sciences (WFUHS)/Wake Forest School of Medicine (WFSM) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The ACCME requires that accredited Providers maintain high standards of quality and documentation in the development and provision of continuing medical education (CME). This Certification Request is intended for WFBH/WFSM faculty and their departments, sections, divisions, institutes, offices, and centers developing regularly scheduled series (RSS) who agree to support and abide by these standards. RSS are defined as daily, weekly, monthly, or quarterly CME activities primarily planned by and presented to an organizations own professional staff; examples include grand rounds, teaching conferences, tumor boards, and journal clubs. Each section of this Certification Request is specifically designed to link with the ACCMEs Updated Accreditation Criteria ( HYPERLINK "http://www.accme.org/dir_docs/doc_upload/b03aa5cc-b017-4395-a41f-8d5d89ac31ca_uploaddocument.pdf" http://www.accme.org/dir_docs/doc_upload/b03aa5cc-b017-4395-a41f-8d5d89ac31ca_uploaddocument.pdf). The Office of Continuing Medical Education (OCME) is responsible for maintaining the CME accreditation granted to WFUHS/WFSM. RSS for which CME sponsorship is sought must be reviewed and approved by the institutional faculty CME Committee. Appropriate CME credit is awarded if sponsorship is approved. Credit can be withdrawn from previously certified activities if actions by the faculty, staff, planning committee members, or teachers/authors threaten WFUHS/WFSMs accreditation. As set forth in the core mission statement of WFSM, the OCME is committed to providing superior, ethical, timely CME to health care professionals, specifically physicians, thereby supporting them in constant self-evaluative improvement and lifelong learning of biomedical knowledge and better enabling them to provide optimal, safe patient care leading to the improved health and well-being of the general public. All certified CME activities must help fulfill this mission. In addition, when developing CME activities, it is important to: 1.) build bridges with other stakeholders through collaboration and cooperation and 2.) participate in a framework for quality improvement. The OCME uses the American Medical Association (AMA) House of Delegates definition of CME educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession. The content of CME is the body of knowledge and skills generally recognized and accepted by the profession as within the basic medical sciences, the discipline of clinical medicine, and the provision of health care to the public. All content must promote improvements in patient care and not a specific proprietary business or commercial interest. (Criterion 10 and the Standards for Commercial Support) Recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. In addition, all scientific research referred to, reported, or used in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection, and analysis. Instructions Departments/sections that are new applicants should first contact/meet with an OCME staff member. Material for newly proposed RSS outside the normal July 1-June 30 fiscal year approval process should be submitted three months in advance (or earlier) of the planned start date. The Certification Request should be completed and returned to the OCME with all required documentation and forms. All sections of the Certification Request must be complete in order to be accepted for review. Incomplete applications will be returned. No modifications should be made to this form. Any specialty-specific acronyms used should be defined. No accreditation, sponsorship, or credit statements can be used in publicity materials until the Certification Request is approved, and all materials must conform to required institutional branding guidelines. Application fees are non-refundable and are due at the time of submission. Certification Request for Sponsorship of a WFBH/WFSM Regularly Scheduled Series (RSS) and AMA PRA Category 1 Credit(s)TM Regularly Scheduled Series (RSS) Title:  FORMTEXT       Sponsoring Department/Section:  FORMTEXT       Start Date: July 1, 2013End Date: June 30, 2014Location (Building & Room #):  FORMTEXT       Frequency & Time(s) (e.g. 3rd Monday of the month, 10:00-11:00 am):  FORMTEXT       Faculty Activity Director:  FORMTEXT      Phone:  FORMTEXT      Fax:  FORMTEXT       E-mail:  FORMTEXT      Pager/Mobile:  FORMTEXT       Staff Coordinator:  FORMTEXT      Phone:  FORMTEXT      Fax:  FORMTEXT       E-mail:  FORMTEXT      Dept. Chair/Section Head:  FORMTEXT       List any additional WFBH departments, sections, divisions, institutes, offices, centers, etc. co-hosting this RSS.  FORMTEXT       A.) Planning Committee Structure: In addition to the above named Faculty Activity Director and Staff Coordinator, list all persons responsible for planning, designing, developing, and implementing this CME activity, including Department Chair/Section Head if applicable. Include names, degrees, and professional titles. [Note: No employee of a commercial interest may serve on the planning committee nor be allowed to influence educational content (nuanced or direct).]* Attach Full Disclosure Statements for all, including Activity Director and Staff Coordinator. Name & Degree:  FORMTEXT      Title:  FORMTEXT      Name & Degree:  FORMTEXT      Title:  FORMTEXT      Name & Degree:  FORMTEXT      Title:  FORMTEXT      Name & Degree:  FORMTEXT      Title:  FORMTEXT      Name & Degree:  FORMTEXT      Title:  FORMTEXT      Name & Degree:  FORMTEXT      Title:  FORMTEXT      *All decisions must be free of the control of commercial interests including: (a.) identification of needs; (b.) the determination of educational objectives; (c.) the selection and presentation of content; (d.) the selection of all persons and organizations in a position to control the content; (e.) the selection of educational methods; and (f.) the evaluation of the activity. (Criterion 7 and the Standards for Commercial Support) OFFICE of CME USE ONLY X RSS  FORMCHECKBOX  EM  FORMCHECKBOX  Renewal Initial Receipt: ______ Initial OCME Review: ______ Faculty Peer Review Request(s) Sent: ______ Peer Review(s) Received: ______ Revision(s) Submitted: ______ Revision(s) Sent Back for Peer Review: ______ Revision(s) Accepted: ______ CME Cte Approval: ______ OCME Program Coordinator: ____ Approved for ______ AMA PRA Category 1 Credit(s)TM Disapproved (description): ______________________________________________________________________________________________________  B.) Professional Practice Gaps, Educational Needs, Desired Results, & Learner Objectives: As outlined in its mission statement, the OCME helps physicians and other health care providers to identify professional practice gaps to recognize the difference between current practice patterns and those potentially achievable, leading to practice improvement and thus better, safer care for patients. (You may use the attached worksheet to help you complete this section though it is not required.) A professional practice gap is defined as the difference between health care processes and outcomes currently in practice and those potentially achievable. (Criterion 2) Put simply, it is actual practice (what learners currently know and/or do) vs. best practice (what they should know and/or do) the problem the CME activity is seeking to solve. These gaps are measured in terms of: Knowledge: being aware of what to do/able to summarize content and discuss application in clinical practice; Competence: knowing how to do it/able to apply content in a simulated practice environment; and/or Performance: actually doing it/applying content in the practice setting. Describe the identified professional practice gaps for this RSS. List the patient care (clinical) and/or health care system (non-clinical) issues that will be the primary focus over this next years RSS. In other words, on what does the department/section need to improve in order to provide better, safer patient care?  FORMTEXT       The above listed professional practice gaps are in (check all that apply):  FORMCHECKBOX  Knowledge  FORMCHECKBOX  Competence  FORMCHECKBOX  Performance What is the current practice for the above listed issues?  FORMTEXT       In comparison, what is considered best practice? What does the data (internal or external) say?  FORMTEXT       How will the RSS close/diminish the above listed professional practice gaps? More simply stated, what are the potential causes of the identified problems? What information/skills need to be shared, taught, learned, or communicated in order to improve the unsatisfactory patient outcomes? Does the learner need to know more, have different strategies, and/or do something differently? State the educational need(s).  FORMTEXT       CME activities incorporate the educational needs (knowledge, competence, and/or performance) that underlie the professional practice gaps. Done prospectively, needs assessments look at gaps from various points of view, showing current practice vs. ideal practice. For RSS, additional needs assessments can be performed for a specific session to further define a professional practice gap. A need can be addressed in more than one session, and new needs can be incorporated over time into a series as long as they are appropriate to the target audience. Indicate the different needs assessments used for this years RSS (check all that apply and attach supporting documentation for those with an *). How were the needs brought to the attention of the planning committee? Accreditation guidelines require that planning committees look outside themselves, i.e. beyond attendance records and past evaluation data when conducting needs assessments. (Criterion 2)  FORMCHECKBOX  Review of Previous Evaluation Data  FORMCHECKBOX  Institutional Requirements or Strategic Plans  FORMCHECKBOX  Focus Groups* (notes/minutes)  FORMCHECKBOX  National or Specialty Society Guidelines (list societies):  FORMTEXT        FORMCHECKBOX  Identification by Internal Medical Staff  FORMCHECKBOX  Literature Reviews* (citations only)  FORMCHECKBOX  Community Health Needs Assessments*  FORMCHECKBOX  New Medical Information  FORMCHECKBOX  Library Requests  FORMCHECKBOX  Referral Data*  FORMCHECKBOX  Translational Science Institute (TSI) Research*  FORMCHECKBOX  Survey Results*  FORMCHECKBOX  Internal Quality Initiatives  FORMCHECKBOX  Feedback from 3rd Party Payers and Regulators*  FORMCHECKBOX  Internet Searches*  FORMCHECKBOX  Expert Opinion  FORMCHECKBOX  Joint Commission Standards  FORMCHECKBOX  Research Findings*  FORMCHECKBOX  Legal, Government, or Regulatory Requirements  FORMCHECKBOX  P&T Committee  FORMCHECKBOX  Maintenance of Certification (MOC) Requirements  FORMCHECKBOX  Interviews* (notes/minutes)  FORMCHECKBOX  IOM, ACGME, and/or ABMS Core Competencies/Requirements  FORMCHECKBOX  Committee Findings* (notes/minutes)  FORMCHECKBOX  Requests from Affiliated Institutions, Groups, or Community Organizations*  FORMCHECKBOX  Patient Chart Audits/Practice/QI Data* (in aggregate only)  FORMCHECKBOX  Other* (describe)  FORMTEXT       Based on the responses to Questions #1 & #2, what are the desired results/the expected impacts on the learner? What are the teaching goals? (Criterion 3) This CME activity is designed to change (check all that apply with explanations and measurement plans for each):  FORMCHECKBOX  Competence (give physicians new abilities/strategies/knowledge):  FORMTEXT       How do you intend to measure these changes? Possibilities include evaluation questions, audience response system, pre-tests, post-tests, surveys, etc.  FORMTEXT        FORMCHECKBOX  Performance (help physicians modify their practices):  FORMTEXT       How do you intend to measure these changes? Possibilities include adherence to guidelines, interviews, focus groups, chart audits, peer review, direct observation, etc.  FORMTEXT        FORMCHECKBOX  Patient Outcomes (help improve patient outcomes):  FORMTEXT       How do you intend to measure these changes? Possibilities include patient feedback, patient chart audits, hospital QI data, changes in mortality and morbidity rates or health status measures, etc.  FORMTEXT       Learner objectives should connect the identified educational need(s) (Question #1e) with the desired result(s) (Question #3) and be framed in terms of the expected changes in competence, performance, and/or patient outcomes. List the learner objectives for this RSS. What should the attendees know and/or be better able to do as a result of participating? Use the attached list of action-oriented verbs. Global learner objectives are acceptable at this stage; more detailed, specific objectives can be created later for each individual RSS session. The number of objectives is not as important as being sure they adequately reflect what is to be achieved at the end of the RSS. At the conclusion of this CME activity, the learner should be better able to:  FORMTEXT       C.) Target Audience: The content of a CME activity should be designed to match learners current or potential scope of professional activities. (Criterion 4) Scope of practice is the range or breadth of a physicians actions, procedures, and processes, or, as defined by the Federation of State Medical Boards, those health care services a physician or other health care practitioner is authorized to perform by virtue of professional license, registration, or certification. In addition to the sponsoring (and any co-sponsoring) department/section, indicate additional specialties of medicine that will be targeted (check all that apply):  FORMCHECKBOX  Anesthesiology  FORMCHECKBOX  Biochemistry  FORMCHECKBOX  Cancer Biology  FORMCHECKBOX  Cardiology  FORMCHECKBOX  Cardiothoracic Surgery  FORMCHECKBOX  Dermatology  FORMCHECKBOX  Emergency Medicine  FORMCHECKBOX  Endocrinology/Metabolism  FORMCHECKBOX  Family & Community  FORMCHECKBOX  Gastroenterology  FORMCHECKBOX  General Internal Medicine  FORMCHECKBOX  General Surgery  FORMCHECKBOX  Gerontology & Geriatrics  FORMCHECKBOX  Hematology & Oncology  FORMCHECKBOX  Infectious Diseases  FORMCHECKBOX  Microbiology/Immunology  FORMCHECKBOX  Molecular Medicine  FORMCHECKBOX  Nephrology  FORMCHECKBOX  Neurobiology & Anatomy  FORMCHECKBOX  Neurology  FORMCHECKBOX  Neurosurgery  FORMCHECKBOX  Obstetrics & Gynecology  FORMCHECKBOX  Ophthalmology  FORMCHECKBOX  Orthopaedic Surgery  FORMCHECKBOX  Otolaryngology  FORMCHECKBOX  Pathology  FORMCHECKBOX  Pediatrics  FORMCHECKBOX  Physiology & Pharmacology  FORMCHECKBOX  Plastic & Reconstructive  FORMCHECKBOX  Psychiatry & Behavioral  FORMCHECKBOX  Public Health Sciences  FORMCHECKBOX  Pulmonary/Critical Care/ Allergy/Immunologic Disease  FORMCHECKBOX  Radiation Oncology  FORMCHECKBOX  Radiology  FORMCHECKBOX  Regenerative Medicine  FORMCHECKBOX  Rheumatology  FORMCHECKBOX  Surgery  FORMCHECKBOX  Urology  FORMCHECKBOX  Other:  FORMTEXT       Will medical students, residents, and/or fellows be included?  FORMCHECKBOX  Yes  FORMCHECKBOX  No [CME activities are intended for practicing health care providers rather than those still in training. As a teaching institution, WFSM encourages medical fellows, residents, and students to attend CME activities, but education specifically designed for those still in training are not applicable for AMA PRA Category 1 Credit(s) TM.] CME activities are primarily targeted to physicians. Is the target audience for this RSS multidisciplinary in nature, i.e. targeted to non-physicians as well?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, list other health care providers/practitioners that are part of the target audience.  FORMTEXT       Are non-WFBH employees invited to attend, i.e. community practitioners?  FORMCHECKBOX  Yes  FORMCHECKBOX  No What is the estimated attendance size?  FORMTEXT       If additional types of continuing education credit, e.g. American Academy of Family Physicians (AAFP), American Congress of Obstetricians & Gynecologists (ACOG), Accreditation Council for Pharmacy Education (ACPE), American Nurses Credentialing Center (ANCC) are needed, list them. (Additional fees may be associated with these credit applications.)  FORMTEXT       D.) Core Competencies: A CME activity should be developed in the context of desirable physician attributes. (Criterion 6) Indicate which of the Institute of Medicine (IOM), Accreditation Council for Graduate Medical Education (ACGME), and/or American Board of Medical Specialties (ABMS) core competencies will be addressed by this RSS (check all that apply).  FORMCHECKBOX  Quality Improvement  FORMCHECKBOX  Use of Informatics  FORMCHECKBOX  Evidence and Practice-Based Learning & Improvement  FORMCHECKBOX  Working in Interdisciplinary Teams  FORMCHECKBOX  Patient-Centered Care  FORMCHECKBOX  Interpersonal Communication Skills  FORMCHECKBOX  Medical Knowledge  FORMCHECKBOX  Professionalism  FORMCHECKBOX  Systems-Based Practice List any other desirable physician attributes that will be addressed, e.g. the American Medical Associations Code of Ethics, the American College of Physicians Ethics and Professionalism Policies and Charter, etc.  FORMTEXT       E.) Barriers to Change, Collaborations, & Non-Educational Strategies: Often times, factors exist outside the control of the learner that can impact patient outcomes. Indicate at least one potential or real non-educational barrier facing the department/section and its faculty and/or staff for the professional practice gap(s)/educational need(s) to be addressed. (Criterion 18)  FORMCHECKBOX  Lack of Time to Assess/Counsel Patients  FORMCHECKBOX  Too Few Resources or Administrative Support  FORMCHECKBOX  Insurance/Reimbursement Issues  FORMCHECKBOX  Lack of Consensus on Practice Guidelines  FORMCHECKBOX  Larger, Health Care System-Type Issues  FORMCHECKBOX  Patient Compliance  FORMCHECKBOX  Costs  FORMCHECKBOX  Other:  FORMTEXT       Indicate any WFBH and/or external stakeholders with whom collaboration or cooperation is possible in order to build bridges to quality and could help address any of the potential or real barriers listed in Question #12. (Criterion 20) WFBH:  FORMCHECKBOX  Other Clinical Departments/Sections (list)  FORMTEXT        FORMCHECKBOX  Nursing  FORMCHECKBOX  Risk Management  FORMCHECKBOX  Organizational Development  FORMCHECKBOX  Best Health  FORMCHECKBOX  PA Program  FORMCHECKBOX  Pharmacy/P&T Committee  FORMCHECKBOX  Maya Angelou Center for Health Equity  FORMCHECKBOX  Food & Nutrition Services  FORMCHECKBOX  Office of Global Health  FORMCHECKBOX  Faith & Health Ministries  FORMCHECKBOX  Legal Department  FORMCHECKBOX  Life Support Education  FORMCHECKBOX  Medical Records  FORMCHECKBOX  WakeOne  FORMCHECKBOX  Patient Relations/Service Excellence  FORMCHECKBOX  Northwest Community Care Network  FORMCHECKBOX  Public Health Sciences  FORMCHECKBOX  Physicians Access Line (PAL)  FORMCHECKBOX  Quality & Performance Analytics  FORMCHECKBOX  Volunteer Services  FORMCHECKBOX  Downtown Health Plaza  FORMCHECKBOX  Center for Integrative Medicine  FORMCHECKBOX  Arts & Health  FORMCHECKBOX  Community Physicians  FORMCHECKBOX  Translational Science Institute (TSI)  FORMCHECKBOX  Office of Research  FORMCHECKBOX  Alumni Affairs/Development  FORMCHECKBOX  Office of Women in Medicine & Science  FORMCHECKBOX  Coy C. Carpenter Library  FORMCHECKBOX  Infection Control  FORMCHECKBOX  Information Services/Academic Computing  FORMCHECKBOX  Audit & Compliance Office  FORMCHECKBOX  Managers of Institutional Initiatives  FORMCHECKBOX  Wake Forest Innovations/Center for Applied Learning  FORMCHECKBOX  WFBH Other:  FORMTEXT       External:  FORMCHECKBOX  Community Organizations  FORMCHECKBOX  Patient Organizations  FORMCHECKBOX  Local or National Societies  FORMCHECKBOX  Regional/Affiliated Health Care Organizations  FORMCHECKBOX  Government Agencies  FORMCHECKBOX  External Other:  FORMTEXT       List the specific organization(s)/group(s):  FORMTEXT       Indicate any non-educational strategies to be used to enhance/reinforce change as an adjunct to the RSS. (Criterion 17)  FORMCHECKBOX  Post RSS Reminders to Attendees  FORMCHECKBOX  Patient Feedback or Surveys  FORMCHECKBOX  Protocols  FORMCHECKBOX  Patient Education Materials  FORMCHECKBOX  Algorithms  FORMCHECKBOX  Order Sets  FORMCHECKBOX  Flow Sheets  FORMCHECKBOX  Personal Patient Outcomes Data  FORMCHECKBOX  Newsletters  FORMCHECKBOX  Display Posters  FORMCHECKBOX  Forms  FORMCHECKBOX  Handouts  FORMCHECKBOX  Chart or Electronic Health Record Reminders  FORMCHECKBOX  Other:  FORMTEXT       F.) Adult Learning Principles, Educational Methodology, & Evaluation: Adult learning is a complex, multistage process that incorporates the learner into the planning and evaluation process. 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CJOJQJaJphp7j3hhe5B* CJOJQJUaJphp(hhe5B* CJOJQJaJphp1jhhe5B* CJOJQJUaJphp"hD,5B*CJOJQJaJph(h=hD,5B*CJOJQJaJph xxxx,x:x*CJOJQJaJ"hbXh [5>*CJOJQJaJ"hbXhSk5>*CJOJQJaJh' 5>*CJOJQJaJhjnCJOJQJaJ<jhKh05B* CJOJQJUaJmHnHphpu7j;hKh05B* CJOJQJUaJphp(hKh05B* CJOJQJaJphp1jhKh05B* CJOJQJUaJphp|}}}~ȼ٪ىy`K(hh6t5B* CJOJQJaJphp1jhh6t5B* CJOJQJUaJphphs:hO?6CJOJQJaJhs:hO?CJOJQJaJ"hCJOJPJQJaJnHtH"hCJOJPJQJaJnHtHhCJOJQJaJhbXhMCJOJQJaJU"hO?CJOJPJQJaJnHtH(hbXhMCJOJPJQJaJnHtHntent-oriented; experience provides the basis for learning, which is focused on material that has immediate relevance. Adults learn by solving genuine problems (reviewing their own issues and daily encounters); reflecting via analogy/comparison (comparing their own experiences to others); practicing and applying new knowledge and strategies; and developing a framework for application (creating plans for implementation). Indicate the appropriate stage(s) of physician learning for this RSS (check all that apply).  FORMCHECKBOX  Recognizing a need for learning when a physician becomes aware that something in his/her practice needs improvement  FORMCHECKBOX  Searching for learning resources when a physician is driven by cognitive dissonance (the difference between what is and what should be)  FORMCHECKBOX  Engaging in learning when learning (formal or informal) becomes more intentional and focused on the problem at hand  FORMCHECKBOX  Trying out what was learned when a physician begins to use newly acquired knowledge or skills and looks to confirm the benefits  FORMCHECKBOX  Incorporating what was learned when a physician integrates the new knowledge or skills into daily practice Educational formats should be appropriate for the setting, objectives, and desired results of the CME activity. (Criterion 5) Indicate what educational design(s)/format(s) will be used (check all that apply). Attach the proposed 2013-2014 schedule as well as the 2012-2013 schedule (as a sample of past activity).  FORMCHECKBOX  Lecture/Didactic  FORMCHECKBOX  Panel Discussion  FORMCHECKBOX  Question & Answer  FORMCHECKBOX  Videoconference  FORMCHECKBOX  Live Webcast/Webinar  FORMCHECKBOX  Archived Webcast/Webinar  FORMCHECKBOX  Live Demonstration  FORMCHECKBOX  Interact. Workshop  FORMCHECKBOX  Simulated Patient  FORMCHECKBOX  Tumor Board  FORMCHECKBOX  Journal Club  FORMCHECKBOX  Pro/Con Debate  FORMCHECKBOX  Lab Exercise  FORMCHECKBOX  Hands-On Practicum  FORMCHECKBOX  Podcast  FORMCHECKBOX  Academic Detailing  FORMCHECKBOX  Roundtable Discussion  FORMCHECKBOX  Case Study  FORMCHECKBOX  Other:  FORMTEXT       Provide a brief description for each selected format including the frequency, e.g. invited guest lecturer the first Monday of the month, journal club the second Monday of the month, and case presentations the third Monday of the month. Include in the description any variations in duration, e.g. case presentations are two hours in length while journal clubs are one hour.  FORMTEXT       Describe the planned evaluation process, including frequency. (Criterion 11) Attach sample document.  FORMTEXT       G.) Funding Sources & Disclosure: Indicate what funding sources will be used (check all that apply).  FORMCHECKBOX  Department/Institutional Funds  FORMCHECKBOX  Government Funds  FORMCHECKBOX  Foundation Grants  FORMCHECKBOX  Pharmaceutical/Medical Device Educational Grants (Criterion 8 and the Standards for Commercial Support)*  FORMCHECKBOX  Pharmaceutical/Medical Device In-Kind Donations/Equipment Loans (Criterion 8 and the Standards for Commercial Support)*  FORMCHECKBOX  Exhibit Fees (Criterion 9 and the Standards for Commercial Support)*  FORMCHECKBOX  Other:  FORMTEXT       *WFBH/WFSM policy requires all commercial funding requests, e.g. educational grants, in-kind donations/equipment loans, and/or exhibit fees be completed and managed by the OCME. Will teachers/authors be paid an honorarium?  FORMCHECKBOX  Yes* (Amount: $ FORMTEXT      )  FORMCHECKBOX  No *WFBH/WFSM policy states honoraria higher than $1500 per day must be approved by the Senior Associate Dean for Academic Affairs. Planners, teachers, and authors may be reimbursed for out-of-pocket expenses consistent with institutional policy. If a teacher or author is listed on a CME activity agenda as facilitating or conducting a presentation or session, but participate in the remainder of the activity as a learner, his/her expenses can be reimbursed and an honorarium can be paid for his/her teacher or author role. No other payment, apart from those paid by WFBH/WFSM, shall be given to the Activity Director, planning committee members, teachers, authors, or others involved with the CME activity. (Criterion 8 and the Standards for Commercial Support) ____________________________________________________________________________________________________________________ Required Attachments: Full Disclosure Statements for Activity Director, Staff Coordinator, and Additional Planning Committee Members including Department Chair/Section Head if applicable Signed CME Financial Agreement with Department Account #/Chartfield Needs Assessment Supporting Documentation Past and Planned RSS Schedules Tumor Board Guidelines & Agreement (as applicable) Sample Evaluation By submitting this Certification Request, the Activity Director and his/her staff understand the proposed RSS must be consistent with the overall mission and policies of WFBH/WFUHS/WFSM and follow all ACCME Essential Areas, Policies, and Updated Accreditation Criteria, including the 2004 ACCME Standards for Commercial Support. In addition, the listed Department Chair/ Section Head is aware and approves of this submission. Submitted by:  FORMTEXT       Date:  FORMTEXT       ________________________________________________________________________________________________________ Optional Professional Practice Gaps, Educational Needs, Desired Results, & Learner Objectives Worksheet Professional Practice GapThis is a Gap in (check all that apply):Educational NeedDesired ResultDesigned to Change (check all that apply):Learner Objective1.)  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