NYC Health + Hospitals

Division of Medical and Professional Affairs

Office of Patient Centered Care

Continuing Medical Education

Activity Application

Please email completed application with all attachments to ContinuingEducationApplications@nychhc.org

CME.NYCHHC.ORG

Every activity that is certified for AMA PRA Category 1 Credit™ must:

1. Conform to the AMA’s definition of CME.

CME Content: Definition and Examples - Continuing medical education consists of educational activities which 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.

2. Address demonstrated educational needs.

3. Communicate to prospective participants a clearly identified educational purpose and/or objectives in advance of participation in the activity.

4. Be designed using AMA approved learning formats and learning methodologies appropriate to the activity’s educational purpose and/or objectives; credit must be based on AMA guidelines for the type of learning format used.

5. Present content appropriate in depth and scope for the intended physician audience.

6. Be planned in accordance with the relevant MSSNY opinions and the ACCME Standards for Commercial Support SM and be non-promotional in nature.

Definition of a Commercial Interest - A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

7. Evaluate the effectiveness in achieving its educational purpose and/or objectives.

8. Document credits claimed by physicians for a minimum of six years.

9. Be certified for AMA PRA Category 1 Credit™ in advance of the activity; i.e. an activity may not be retroactively approved for credit.

10. Include the AMA Credit Designation Statement in any activity materials that reference CME credit with the exception of “save the date” or similar notices.

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NYC Health + Hospitals

Core requirements for certifying activities for AMA PRA Category 1 Credit™

CME.NYCH

The complete application package must be submitted at least six (6) weeks before the planned program activity. Please submit one (1) copy of the completed application to:

Office of Patient Centered Care, 125 Worth Street, 4th Fl./Ste. 418, New York, NY 10013 or email a Microsoft Word copy of the application to Alfreda.weaver@nychhc.org or Olivia.Greene@nychhc.org.

There will be no retrospective approval or accreditation of any program activity; no credits may be awarded to programs conducted which had not been previously approved.

Only one application per CME activity to be given multiple times (one program repeated in various facilities on different dates), or a series of learning sessions (grand rounds, etc.) need to be completed.

Append a draft of the program announcement and program agenda with the appropriate CME accreditation statement, learning objectives, financial disclosure from faculty, and financial support from other organizations. Brochures, program announcements, and publications used to promote or distributed at the program activity must include the following statements:

CME Accreditation Statement for Direct Providership:

NYC Health + Hospitals is accredited by The Medical Society of the State of New York to provide continuing medical education for physicians.

NYC Health + Hospitals designates this (enter type of learning activity) educational activity for a maximum of (number of credits) AMA PRA Category 1 Credit(s)TM. Physicians should claim only credit commensurate with the extent of their participation in the activity.

CME Accreditation Statement for Joint Providership:

NYC Health + Hospitals is accredited by The Medical Society of the State of New York to provide continuing medical education for physicians.

This activity has been planned and implemented in accordance with the Accreditation Requirements and Policies of the Medical Society of the State of New York (MSSNY) through the joint providership of NYC Health + Hospitals and (Name the Non-Accredited Provider). NYC Health + Hospitals is accredited by MSSNY to provide continuing medical education for physicians. NYC Health + Hospitals designates this (Type of Activity) for a maximum of (Number of Credits) AMA PRA Category 1 Credits™. Physicians should claim only credit commensurate with the extent of their participation in the activity.

A program announcement template and other documents related to the application, as well as samples, can be found on our website at http://cme.nychhc.org.

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CME.NYCHHC.ORG

NYC Health + Hospitals Continuing Medical Education Committee

Checklist – for CME Programs

Name of Program:

Program Type: (Choose One) Single Activity, Regularly Scheduled Series (Grand Rounds, Performance Improvement, Journal Club, Morbidity& Mortality, Review and Update, Breakthrough, Simulation, Training)

Program Date:

Length of Program Run: (Choose One) Once, Weekly, Monthly, Annually

Program will run: (Choose One) Once, Weekly, Bi-weekly, Monthly

Total CME Credits Requested: Total Hours of Instruction to Be provided:

Number of Presenters:

YES NO N/A

Signed Letter of Agreement (If applicable) ☐ ☐ ☐Copy of Announcement / Advertisement ☐ ☐ ☐Copy of Agenda ☐ ☐ ☐Budget form completed ☐ ☐ ☐Financial Disclosure & Conflict of Interest Forms Signed for each planner and presenter ☐ ☐ ☐Each presenter CV, or Resume’ included ☐ ☐ ☐Additional Documents Attached to ApplicationDescribe: ☐ ☐ ☐

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FORM 1 GENERAL DESCRIPTION OF CME PROGRAM ACTIVITY

I. Title of Activity:

II. Presenting Organization:

III. Location of Educational Activity:

IV. Course Director(s): Contact Person:Name: Name Address: Address: Email: Email: Telephone: Telephone:

V. Type of Providership requested: (Choose One)

☐Joint Providership (applicant is a non-accredited non - NYC Health + Hospitals provider)☐Direct Providership (applicant is a NYC Health + Hospitals provider)☐Co-Providership (applicant is an Accredited Provider)

VI. Date(s) for activity (For regularly scheduled series please include documentation of scheduled dates): 1. 6.

2. 7.

3. 8.

4. 9.

5. 10.

VII. Screening Criteria (Note: If none of the following apply, please reconsider the need for this educational intervention)☐ Content is based on evidence that constitutes ‘best practices’☐ Gap exists between current and best practices☐ Closing the gap will result in improvement in the health and, or, outcome of patients☐ The proposed educational intervention will result in change in practice

VIII. Target Audience: ☐ MD ☐ DO ☐ DDS Other:

a. Will this program be open to non-corporate providers? ☐ No ☐ Yesb. Will fees be charged for participation in this program? ☐ No ☐ Yes

IX. Number of AMA PRA Category 1 Credit(s)TM requested:

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FORM 2 FINANCIAL DISCLOSURE & CONFLICT of INTEREST

I. Will there be commercial sponsors or external funding source for this program? ☐Yes ☐ No

If yes, please identify funding source and attach Commercial Support Agreement: 1.2.

If not, how will the activity be funded?

How will support or lack of support be disclosed to the learners prior to the activity?

II. Promotional Activities

A. Will there be commercial exhibits and, or, items from commercial interest for participants in this program activity?☐Yes ☐ No

If YES, how will you manage the separation of the exhibitors from the educational rooms and learners?

(Note: Commercial exhibits are not permitted at the entrance to, or on a direct or unavoidable path to the educational program activity, or in the same room where program activities will be provided.)

B. Will there be meals served supported by commercial interests? ☐ Yes ☐ No

III. Attach proposed/draft of Program Announcement to include the following information: Must be included for application to be complete

A. Program Learning Objectives (minimum of three)

B. CME accreditation statement:Direct ProvidershipThe NYC Health + Hospitals is accredited by the Medical Society of the State of New York to sponsor continuing medical education for physicians.

The NYC Health + Hospitals designates this (Insert learning format here) for a maximum of ( number of credits ) AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

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Criteria 7: The provider develops activities/educational interventions independent of commercial interest (SCS 1, 2 & 6)Criteria 8: The provider appropriately manages commercial support (if applicable, SCS 3).Criteria 9: The provider maintains a separation of promotion from education (SCS 4).Criteria 10: The provider actively promotes improvements in health care & NOT proprietary interests of commercial

Prior to the beginning of the CME activity, learners must be informed of all relevant financial relationships of the planners and presenters. It must also be disclosed even if planners and presenters have no relevant financial relationships. Complete form 15 and include as a handout or in learning materials.

Joint Providership The NYC Health + Hospitals is accredited by the Medical Society of the State of New York to sponsor continuing medical education for physicians.

This activity has been planned and implemented in accordance with the Accreditation Requirements and Policies of the Medical Society of the State of New York (MSSNY) through the joint providership of NYC Health + Hospitals and (Name the Non-Accredited Provider). NYC Health + Hospitals is accredited by MSSNY to provide continuing medical education for physicians. NYC Health + Hospitals designates this (Type of Activity) for a maximum of (Number of Credits) AMA PRA Category 1 Credits™. Physicians should claim only credit commensurate with the extent of their participation in the activity.

C. Financial disclosure and conflict of interest statement: (statement must be included on the advertisement/marketing materials)

Participating faculty members and planners have no relevant financial relationships to disclose: (insert names of faculty members and planners)

Or The following faculty members and planners asked to disclose information about their financial relationships:

Insert name of faculty members and planners Name of commercial interest(s) and the Nature of the relationship(s)

D. Financial support from other organizational funding sources:

This activity is supported by an unrestricted educational grant from:

IV. Disclosure: A Financial Disclosure Form (FORM-8) must be completed by all presenters/planners. This is required if there is or is not commercial support for the activity.

A. Have you received an FORM-8 for all planners and presenters: ☐ Yes ☐ No Attach completed disclosures from all planners, presenters and moderators.

B. Has any planner or presenter refused to sign an FORM-8? ☐ Yes ☐ No If yes, how was this managed?

C. Are there any conflicts of interest resulting from a financial relationship? ☐ Yes ☐ No

If yes, describe how the conflict of interest will be addressed?

D. Describe how you plan to make these disclosures to your learners prior to the start of the activity: (see Written Disclosure / Accreditation and Objectives Information – Form 15)

FORM 3 NEEDS ASSESSMENT for the EDUCATIONAL ACTIVITY

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Criterion 2: The provider incorporates into CME activities the educational needs (knowledge, competence, or performance) that underlie the professional practice gaps of their own learners.

Competence “Knowing how to do something” “… a combination of knowledge, skills and performance…the ability to apply knowledge, skills and judgment in practice” “The simultaneous integration of knowledge, skills & attitudes required for performance in a designated role and setting.” ≠ Competency “An underlying characteristic…causally related to effective or superior performance in a job”Performance: What is actually done in practice? It is based on one’s competence but is modified by system factors & the circumstances.”

I. Why is this learning session necessary?

This learning session has been designed to meet identified gaps and/or to address the specific performance measures:

1. Why is this learning session necessary?

2. Why do physician-learners need to learn about this topic?

3. How was the gap in knowledge, competence, or performance measure determined or identified?☐ Learner Evaluations ☐ Medical Audit ☐ New technology or technique* ☐ Objective data or statistics*☐ Quality Improvement Report* ☐ Regulatory Changes ☐ Risk Management ☐ Survey ☐ Other* *Define:

4. List Identified gaps and the planned learner outcome:Identified Gap in

Competence / Performance / Pt. Outcome Learner Outcome

II. Has there been any participation by a commercial interest in the needs assessment and/or planning for this learning activity? ☐ Yes ☐ No

If YES, please identify commercial interest:

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FORM 4 LEARNING OBJECTIVES

I. State Learning Objectives for the Program Activity.

Please ensure that the learning objectives are designed to meet the identified gaps in knowledge and skills, or performance measures.

At the conclusion of the course, the participants should be able to (1 – 2 objectives per hour):

1.

2.

3.

II. Educational Methods to Achieve Learning ObjectivesIndicate the educational methods that will be used to achieve aforementioned objectives for this CME program activity.

☐ Lecture ☐ Performance Improvement Activity

☐ Case Presentation ☐ Committee Work

☐ Workshop ☐ Internet-based Learning Session/Web Conference

☐ Panel Discussion ☐ Other

Lectures, Case Presentations, Workshops, or Panel Discussions: Please complete form 14 for each presentation

Performance Improvement Activity: Append a description of the activity by which the participants can learn about specific performance improvement measures including: a) assessment of a particular health outcome in their practice; b) development and application of specific interventions or measures over a useful interval designed to improve health outcome; and c) evaluation of their performance through a reassessment of the particular health outcome addressed in (b).

Committee Work: Append the nature of the work of the committee, the specific item for discussion or work to be completed during the accredited session and the Learning Objective for that particular session. Invited presenters to the Committee meeting will be considered ‘faculty’ and must comply with all other requirements for faculty members.

Internet-based Learning Sessions, Enduring Materials and other participant-initiated learning activities: Append the description of the activity, process of accessing the learning modules, evaluation, and documentation of completion of learning activities, and linkage to the NYC Health + Hospitals CME website.

III. Educational Activity Overview Use Form 14 - Educational Activity Table - to Supply Items 1 through 51. Objectives: Indicate what the participant will be able to do at the conclusion of the activity. Objectives should be

written in measurable terms given the time frame and teaching method. An average of 1-2 objectives per hour is realistic.

2. Content: Itemize key points that will be addressed with each objective. Content must be more than a restatement of the objective and must be related to the objective.

3. Time Frame: Indicate the number of minutes for each objective for live presentations.4. Presenter: List the faculty who will be addressing each objective (this is not applicable for content specialists).5. Teaching Methods: List the methods, strategies, materials, and resources to be used by faculty to cover each

objective.

IV. Attach a program agenda with start and end times of each presenter and include non-educational time.

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Criterion 3: Provider generates activities/education interventions designed to change competence, performance or patient outcomesEducation objectives are not simply what participants will learn; they must clarify outcomes for change in competence, performance, patient outcomes.

FORM 5 BARRIERS and OPPORTUNITIES

I.Barriers and Opportunities

What could block the learner from implementing the new learned behaviors, strategies or skills taught in this activity? (e.g., staffing issues, policy or schedule restrictions, insurance reimbursement issues, lack of resources, politics, etc.)

☐ This activity addresses no relevant system barriers.

☐ The following barriers have been identified and will be addressed in the educational activity (add lines as needed)

II. Partnering and Collaborations Are there other organizations with which you could partner or are partnering that are also working on this topic?

☐Yes ☐ No If YES, describe:

How could internal or external groups be included to help address or remove barriers as identified in question 1?

III. Non‐educational Interventions These tools support achievement of your intended results for this activity. List any other strategies that will be used to enhance the potential for physician change or reinforce the desired educational results.

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Criteria 18: The provider identifies factors outside the provider’s control that impact on patient outcomes.Criteria 19: The provider implements educational strategies to remove, overcome or address barriers to physician change.Criteria 20: The provider builds bridges with other stakeholders through collaboration and cooperation

Criteria 17: The provider utilizes non-education strategies to enhance change as an adjunct to its activities/educational interventions (e.g., reminders, patient feedback).

FORM 6 PHYSICIAN COMPETENCIES and ATTRIBUTES

Physician Competencies and AttributesCompetencies and Attributes are national goals for physicians associated with targeted specialty(ies) that should be addressed whenever possible in planning CME. Based on the list of physician attributes below, which competency areas have been addressed during the planning of this CME activity? Check all that apply. (C6)

Institute of Medicine Core Competencies ABMS Maintenance of Certification ACGME/ABMS Competencies

Provide patient-centered care Evidence of professional standing Patient care

Work in interdisciplinary teams Evidence of a commitment to lifelong learning Medical knowledge

Employ evidence-based practice Evidence of cognitive expertise Practice-based learning and improvement

Apply quality improvement Evidence of evaluation of performance in practice Interpersonal and communication skills

Utilize informatics Professionalism

System‐based practice

Institute of Medicine Core Competencies☐ Provide patient-centered care - identify, respect & care about patient differences, values, preferences & expressed needs; relieve pain &

suffering; coordinate continuous care; listen to, clearly communicate with & educate patients; share decision making & management; continuously advocate disease prevention, wellness, healthy lifestyle promotion, including focus on population health

☐ Work in interdisciplinary teams – cooperate, collaborate, communicate & integrate care in teams to ensure care is continuous & reliable. Employ evidence-based practice. Integrate best research with clinical expertise & patient values for optimum care & participate in learning and research activities to the extent feasible

☐ Apply quality improvement - identify errors & hazards in care; understand & implement basic safety principles, like standardization and simplification; continually understand & measure quality of care in terms of structure, process & outcomes in relation to patient & community needs. Design & test interventions to change processes & systems of care, with objective of improving quality

☐ Utilize informatics -communicate, manage, knowledge, mitigate error, and support decision making using information technology☐ Employ evidenced based practice

ACGME/ABMS Competencies☐ Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.☐ Medical knowledge of established & evolving biomedical, clinical, and cognate sciences & application of knowledge to patient care☐ Practice-based learning and improvement that involves investigation and evaluation of own patient care, appraisal and assimilation of

scientific evidence, and improvements in patient care☐ Interpersonal & Communication skills that result in effective information exchange & teaming with patients, families & other health

professionals☐ Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and

sensitivity to a diverse patient population☐ Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and

system for health care and the ability to effectively call on system resources to provide care that is of optimal value

ABMS Maintenance of Certification☐ Evidence of professional standing, such as an unrestricted license that has no limitations on the practice of medicine☐ Evidence of a commitment to lifelong learning and involvement in a periodic self assessment process to guide continuing learning☐ Evidence of cognitive expertise based on performance on an examination. That exam should be secure, reliable and valid. It must contain

questions on fundamental knowledge, up-to date practice-related knowledge, and other issues like ethics and professionalism☐ Evidence of evaluation of performance in practice, including the medical care provided for common/major health problems and

physicians behaviors, such as communication and professionalism, as they relate to patient care

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Criterion 6: The provider develops activities/educational interventions in the context of desirable physician attributes.

FORM 7 FACULTY and PROGRAM PLANNING COMMITTEE

I. Provide a list of faculty members and the program planning committee, including the relationship with any commercial interests of each of the individuals in this list.

Name & Credentials Organizational Affiliation

Participant Status Commercial Interest Affiliation (if any)Planner Faculty

II. Append the Curriculum Vitae or Resume and a signed disclosure form for each of the individuals in this list to this packet.

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FORM 8 FINANCIAL DISCLOSURE FOR INDIVIDUAL FACULTY, MODERATOR, PROGRAM DIRECTOR & PLANNING COMMITTEE MEMBER

Title of Activity: Location: Date(s):

1. Have you (or your spouse/partner) had a personal financial relationship in the last 12 months with the manufacturer of the products or services that will be presented or discussed in this CME activity ☐ Yes ☐ No

If No skip to DECLARATION section below. If Yes please list your disclosure and resolutions below.

Commercial Interest Nature of Relevant Financial Relationship

Name of Company

Employee, Grants/Research Support recipient, Board Member, Advisor or Review Panel Member, Consultant, Independent

Contractor, Stock Shareholder (excluding mutual funds), Speakers’ Bureau, Honorarium recipient, Royalty recipient, Holder of

Intellectual Property Rights, or Others (specify) 1.2.3.4.5.

2. Resolution of Conflict of Interest

Faculty☐ I will support my presentation and clinical recommendations with the ‘best available evidence’ from the medical

literature.☐ I will refrain from making recommendations regarding products or services, e.g., limit presentation to pathophysiology,

diagnosis, and/or research findings.☐ I will recommend alternative presenter for this topic for the planning committee’s consideration.☐ I will submit my talk in advance to allow for adequate peer review.☐ I will or have divested myself of this financial relationship.

Planners/Others☐ To the best of my ability, I will ensure that any speakers or content of this program activity is independent of commercial

bias.☐ I will recuse myself from planning activity content in which I have conflict of interest.

Declaration: I will uphold academic standards to ensure balance, independence, objectivity, and scientific rigor in my role in this CME activity. In addition, I agree to comply with the requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Signature: Date: The typed name listed above serves as the electronic signature of the individual completing this Financial Disclosure Form and attests to the accuracy of the information given above.

Print Name:

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FORM 9 BUDGET FOR THE CME PROGRAM ACTIVITY

Include a preliminary budget for this educational activity including all (and potential) expenses and revenues

Title: Location: Date(s):

Program Director(s):

Estimated Expenses: (Please Itemize)

Description Amount

Estimated Income from All Sources: (Please itemize and include name of entities providing: commercial support, grants, fees, and others).

Commercial Support Grants Fees OthersProviding

Entity Amount Providing Entity Amount Providing

Entity Amount Providing Entity Amount

Total Income:

Total Expenses:

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$

$

FORM 10 EVALUATION OF THE EFFECTIVENESS OF THE PROGRAM ACTIVITY

I. Evaluation Tools (including Outcomes Evaluation Assessment) How will you determine if the result you intended for learners has actually been achieved?

METHOD choices: Post-activity Evaluation (measures change to competence) ☐Long-term Post-activity Evaluation (measure change to performance / patient outcomes) ☐Pre-Post Test (measures immediate learning) ☐Learning Contract (commitment-to‐change question) ☐Audience Response System (identifies if learners understand content and provides learning reinforcement) ☐Focus Group (qualitative measurement to seek more in depth information) ☐Post Test (measures transfer of knowledge) ☐Case discussion or vignette (measures application of knowledge to practice / competence) ☐Health Outcome indicators ☐Medical records review before and after activity ☐Skills or Competence Assessments ☐Other: (Describe) ☐

II. Indicate the anticipated outcome of the learning activity:

a. Do you plan to change Knowledge/Competence ☐ Yes ☐ No b. Describe the evaluation tools selected for this activity and rationale for the selection.

c. Do you plan to change Performance ☐ Yes ☐ No d. Describe the evaluation tools selected for this activity and rationale for the selection.

e. Do you plan to change Patient Outcomes ☐ Yes ☐ No f. Describe the evaluation tools selected for this activity and rationale for the selection.

III. Submit to the CME Program within 15 business days of the date of the CME activity the following:

1. Completed ‘Participant’s Evaluation and Attendance Attestation’ forms (No credits or certificate of attendance will be provided to participants without completed form).

2. Completed ‘Director’s Evaluation form’.3. Copy of the Participant Sign-In or Attendance Sheet.4. Completed activity summary evaluation.5. Advertisement.

IV. Indicate when the results of any additional assessment(s) for program effectiveness will be completed and submitted:

FORM 10-A PROGRAM DIRECTOR’S EVALUATION

Title of Activity: 15

Criterion 11: The provider analyzes changes in learners (competence, performance, or patient outcomes)

Location:

Date(s):

1. The CME learning session achieved its learning objectives:

2. The faculty is effective and achieved individual learning objectives:

3. Conflict of interest and financial relationship with commercial interests were fully disclosed:

4. The facility (including the technical and logistical arrangement) was conducive to learning:

5. Indicate when the results of other assessment for program effectiveness will be available and submitted:

Comments:

Program Director’s Signature Date

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1 = Strongly Agree, 2 = Agree, 3 = Somewhat Agree, 4 = Disagree, 5 = Strongly Disagree

The typed name listed above serves as the electronic signature of the individual completing this Program Director’s Evaluation Form and attests to the accuracy of the information given above.

FORM 11 PARTICIPANTS SIGN-IN SHEET

Title of Activity: Location: Date(s):

Name Please Print

Clinical Title

MD, DO, RN,

NP, PA,

MSW

Signature Facility Email AddressPlease Print

Submit to CME and CE Program office no later than one month after the CME or CE Program Activity has been completed.

This is a sample sign-in sheet. You may use your own; however, each attendance sheets must have all of the above identified categories.

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FORM 12 FINANCIAL DISCLOSURES for the PRESENTING ORGANIZATION

Title of Activity: Location: Date(s):

Has external sources of funding been requested/received for this CME activity? ☐ Yes ☐ No

If Yes, Please identify

Source of External Fund or ‘In-kind’ Contribution: Address: Amount of Fund Requested/Received:

Source of External Fund or ‘In-kind’ Contribution: Address: Amount of Fund Requested/Received:

Source of External Fund or ‘In-kind’ Contribution: Address: Amount of Fund Requested/Received:

Source of External Fund or ‘In-kind’ Contribution: Address: Amount of Fund Requested/Received:

Please use additional pages if needed.

Note: If source of funds is a commercial interest(s), please complete and append Form 13: Written Agreement for Commercial Support. Complete an ‘agreement’ with each commercial sponsor.

Program Director: Date:

Signature: The typed name listed above serves as the electronic signature of the individual completing this Financial Disclosure Form and attests to the accuracy of the information given above.

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Form 13 WRITTEN AGREEMENT FOR COMMERCIAL SUPPORT

Title of Activity: Location: Date(s):

Commercial Sponsor: Address: Contact Person: Email: Telephone No.: Fax:

Terms, Conditions, and Purposes

1. This activity is for scientific and educational purposes only and will not promote any specific proprietary business interest of the Commercial Sponsor.

2. The Director(s) of the CME activity Is responsible for the identification of the educational need, content of the program activity, learning objectives, selection of

faculty, educational methods, and evaluation of the activity; Ensures the objectivity of any discussion of commercial products which occurs during the program activity, as well as

disclosures, to the extent possible of limitations of data presented about the commercial product; and Requires faculty to disclose when a product is not approved in the US for the use under discussion; Will accept the full amount of the educational grant, and will make all decisions regarding the disposition and disbursement of

the funds from the Commercial Sponsor. Will furnish the Commercial Sponsor, upon request, with the full details of the expenditure of the educational grant.

3. The Commercial Sponsor: Will not require NYC Health + Hospitals CME Program and the Program Director(s) to accept advise or services concerning

faculty, authors, or participants or other educational matters as conditions of receiving this grant; Will inform NYC Health + Hospitals CME Program of the educational grant to support this activity; no other payments apart

from the educational grant shall be made to the Program Director(s), planning committee members, teachers or authors, joint sponsors, or any others involved with this activity;

Will not include advertising materials and editorial on the same products in any printed materials for this activity; Will not conduct commercial promotional activities including distribution or exhibition of product-promotional material or

product-specific advertisement of any type, in the educational space immediately before, during or after the CME or activity; Will not be the agent providing the CME activity to the learners.

4. DisclosureThe NYC Health + Hospitals CME Program and the Program Director(s) will ensure that the source of support from the Commercial Sponsor, either direct or ‘in-kind,’ is disclosed to the participants, in program brochures, syllabi, and other program materials, and at the time of the activity. This disclosure will not include the use of trade name or a product-group message.

The acknowledgment of commercial support may state the name, mission, and clinical involvement of the company or institution and may include corporate logos and slogans, if they are not product-promotional in nature.

The director(s) and the commercial sponsor agree to abide by all requirements of the ACCME and MSSNY “Standards for Commercial Support of Continuing Medical Education,” the American Dental Association, and the New York State Education Department.

Signature HHC Director: Signature Commercial Sponsor:

Print Print

Date: Date:

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Commercial Interest: A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

Total Minutes (on this planning table) divided by 60 minutes = contact hour(s)

Completed By: Name and Credentials Date

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NYC Health + HospitalsEducational Planning Table

Title of Activity:

Total # of Contact Hours: AMA PRA Category 1 CreditsTM:

Learning Outcome(s): (write as an outcome statement, e.g. "The purpose of this activity is to enable the learner to…..

Select all that apply: ☐ Nursing Professional Development ☐ Social Work Professional Development ☐ Patient Outcome☐ Physician Professional Development ☐ Other: Describe:

CONTENT (Topics)Provide an outline of the content

TIME FRAME PRESENTER/AUTHOR TEACHING METHODS/LEARNER ENGAGEMENT STRATEGIES

Learner Objectives Main Topic

Content

Approximate time required for

content (minutes)

List First Name, Last Name List the learner engagement strategies to be used by Faculty, Presenters, Authors

Use example above/below when completing this A clear objective states what the learner will be able to

do upon completion of the educational activity, in terms of behavioral It identifies the desired outcome; whereas, the content for

the activity is the information that supports achieving the objective, and not a restatement.

For every 60 minutes of content you must have a minimum of 1 - 2 objectives

Examples:PowerPoint PresentationLectureRole PlayQ & A

Learner Objectives:

Main Topic:1. Content:

1.

1.List the evidence-based references used for developing this educational activity (include year and author):

FORM 14

Name of Activity:

Absence of Funding: This activity has/ will not receive any financial outside financial support ☐ Yes ☐ No

Funding Disclosure: This activity supported by an unrestricted educational grant from

Date and Time:

Location of Activity:

Speaker Name and Title:

Objectives:1.2.3.

Accreditation StatementNYC Health + Hospitals is an accredited provider of continuing medical education by the Medical Society of the State of New York (MSSNY) an accredited approver of continuing medical education by the Accreditation Council for Continuing Medical Education (ACCME).

The NYC Health + Hospitals designates this (insert learning format) for a maximum of (insert number of credits) AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Disclosure Statement

Policies and standards of the NYC Health + Hospitals and the Accreditation Council for Continuing Medical Education require that speakers and planners for continuing medical education activities disclose the presence or absence of any relevant financial relationships they may have with commercial interests whose products, devices or services may be discussed in the content of a CME activity.

The following speakers and planners have no relevant financial relationships to disclose:

The following speakers and planners asked us to disclose information about their financial relationships:(insert names of speakers and planners along with the name of the commercial interest(s) and the nature of the relationship(s)

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NYC HEALTH + HOSPITALS

Written Disclosure/Accreditation and Objective Information

FORM 15

NYC HEALTH + HOSPITALSCONTINUING PROFESSIONAL EDUCATION

Title of Activity: Activity Code:

Date: Location:

Circle the number that best describes your rating of each statement Poor Fair Good Excellent1. Did the instructor relate the course objectives to the overall goal

& purpose of this learning activity? 1 2 3 4

2. To what extent were the following objectives of this learning activity achieved?

a) 1 2 3 4

b) 1 2 3 4

c) 1 2 3 43. Was the program relevant to your practice/discipline? 1 2 3 44. Were the training materials presented clearly, accurately and

helpful toward the learners understanding of the course? 1 2 3 4

5. Were the teaching strategies and tools appropriate? 1 2 3 46. The degree of confidence I have that I will use the knowledge

from this training? 1 2 3 4

7. Rate the effectiveness of each presenter by circling the number(1 = Poor, 2 = Fair, 3 = Good, 4 = Excellent)

Knowledge of Subject

Presentation orderly and

understandable

Debriefing discussion

engaging/organized

Small groups, role playing & assignments

a. 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4b. 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4c. 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

8. Instructor(s) establish/maintain appropriate teaching strategies? 1 2 3 49. Overall assessment of this educational activity? 1 2 3 410. Was this program fair, balanced, and free of commercial bias? Yes No11. The provider of the activity has disclosed in writing or verbally

the conflict of interest or lack thereof declared by the planners and presenters/content specialists?

Yes No

The strengths of the program were:

What changes will you make in your clinical practice based on this learning activity?

How will you know in your work environment if this training was effective?

In 3 months’ time, what difference do you anticipate seeing in your work environment because of this training?

Additional Comments:

Check Appropriate Box(es):MD DO DDS PA NP RN LPN LMSW / LCSW PsyD Other

PARTICIPANT EVALUATION & ATTENDANCE ATTESTATION TYPE: CE HRS ☐ CME ☐ CEU ☐Email: _______________________________________ Name: ________________________________

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CE hrs./CME/CEU credits or Certificate of Attendance is awarded upon completion of a legibly signed and submitted evaluation form.PLEASE PRINT LEGIBLY

NYC HEALTH + HOSPITALSCONTINUING PROFESSIONAL EDUCATION

Title of Activity: Activity Code:

Date: Location:

Total # of Participants: ________ MD/DO: ________ RN/NP: ________ SW: ________ Other: ________Summarize participants rating of each statement Poor Fair Good Excellent1. Did the instructor relate the course objectives to the

overall goal & purpose of this learning activity? % % % %

2. To what extent were the following objectives of this learning activity achieved?a) % % % %b) % % % %c) % % % %

3. Was the program relevant to your practice/discipline? % % % %

4. Were the training materials presented clearly, accurately and helpful toward the learners understanding of the course?

% % % %

5. Were the teaching strategies and tools appropriate? % % % %6. The degree of confidence I have that I will use the

knowledge from this training? % % % %

7. Summarize participants rating of each presenterKnowledge of

SubjectPresentation orderly and

understandable

Debriefing discussion

engaging/organized

Small groups, role playing &

assignments(1 = Poor, 2 = Fair, 3 = Good, 4 = Excellent) 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

a. % % % % % % % % % % % % % % % %

b. % % % % % % % % % % % % % % % %

c. % % % % % % % % % % % % % % % %8. Instructor(s) establish/maintain appropriate

teaching strategies? % % % %

9. Overall assessment of this educational activity? % % % %10. Was this program fair, balanced, and free of

commercial bias? Yes % No %

11. The provider of the activity has disclosed in writing or verbally the conflict of interest or lack thereof declared by the planners and presenters/content specialists?

Yes % No %

The strengths of the program were:

What changes will you make in your clinical practice based on this learning activity?:

How will you know in your work environment if this training was effective?:

In 3 months’ time, what difference do you anticipate seeing in your work environment because of this training?:

Additional Comments:

ACTIVITY EVALUATION SUMMARY

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CREATING A NEW PROFILE / UPDATING AN EXISTING PROFILECREATING A PROFILE:

1. GO TO THE CPE WEBSITE ON THE NYCHHC INTRANET SITE AT HTTP://CME.NYCHHC.ORG

2. UNDER THE SECTION TITLED LOGIN, CLICK ON THE “SIGN UP NOW!” BUTTON

3. THE PROFILE PAGE WILL OPEN

4. COMPLETE THE FORM IN ITS ENTIRETY. PLEASE DO NOT LEAVE BLANKS!

5. LICENSE CODE SECTION IS FOR SOCIAL WORKERS PROFESSIONAL LICENSE NUMBER.

6. ONCE YOU HAVE COMPLETED THE REGISTRATION FORM, CLICK ON THE TAB LABELED REGISTER

7. YOU ARE NOW SUCCESSFULLY REGISTERED AS A PARTICIPANT IN THE CPE SYSTEM.

8. MAKE A NOTE OF YOUR USER NAME AND PASSWORD. THIS IS YOUR ACCESS INTO THE SYSTEM.

UPDATING AN EXISTING PROFILE:

1. LOG ONTO THE CPE WEBSITE - HTTP://CME.NYCHHC.ORG

2. LOOK FOR THE LOGIN SECTION (ON THE RIGHT SIDE)

3. ENTER YOUR USERNAME (EMAIL ADDRESS) AND PASSWORD. CLICK ON TO THE GO BUTTON.

4. THE WELCOME SCREEN WILL APPEAR. CLICK ON TO THE GO BUTTON.

5. THE NEXT SCREEN WILL DISPLAY THREE TABS. “MY PROGRAMS”, “CPE TRACKER” AND “MY ACCOUNT INFO”

6. CLICK “MY ACCOUNT INFO” AND MAKE NECESSARY CHANGES TO YOUR PROFILE.

7. CLICK ON THE UPDATE TAB IN THE LOWER LEFT CORNER.

8. YOU HAVE SUCCESSFULLY UPDATED YOUR PROFILE. ANY CHANGES WILL TAKE EFFECT UPON CLOSING THE ACCOUNT.

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Continuing Professional Education

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RETRIEVING EDUCATIONAL CREDITS OR CERTIFICATES

CERTIFICATE RETRIEVAL AND CREDIT VERIFICATION:

1. LOG ONTO THE CPE WEBSITE - HTTP://CME.NYCHHC.ORG

2. LOOK FOR THE LOGIN SECTION (ON THE RIGHT SIDE)

3. ENTER YOUR USERNAME (EMAIL ADDRESS I.E., @DOMAIN.ORG ETC.) AND PASSWORD. CLICK ON TO THE GO BUTTON

4. THE WELCOME SCREEN WILL APPEAR. CLICK ON TO THE GO BUTTON.

5. THE NEXT SCREEN WILL DISPLAY THREE TABS. “MY PROGRAMS”, “CPE TRACKER” AND “MY ACCOUNT INFO”

6. CLICK THE TAB “CPE TRACKER”

7. ON THE SAME ROW LOOK TO YOUR RIGHT. LOCATE THE ‘SELECT YEAR’ SECTION. CLICK ON THE DOWN ARROW AND SELECT THE YEAR YOU CHOOSE TO VIEW. THE CERTIFICATES WILL BE LISTED BY PROGRAM NAME.

8. YOU CAN VIEW YOUR CREDITS OR PRINT YOUR CERTIFICATES BY CLICKING ON THE CERTIFICATE LOCATED UNDER THE VIEW/PRINT COLUMN.

9. IF YOU HAVE FORGOTTEN YOUR USERNAME OR PASSWORD CLICK “FORGOT USERNAME OR PASSWORD .” A BOX WILL OPEN, ENTER REQUIRED INFORMATION, SUBMIT AND CLOSE WINDOW. YOU SHOULD RECEIVE AN EMAIL SHORTLY THEREAFTER.

IF YOU HAVE ANY QUESTIONS OR PROBLEMS CONTACT VIA EMAIL:

OLIVIA GREENE: OLIVIA.GREENE@NYCHHC.ORG

ALFREDA WEAVER: ALFREDA.WEAVER@NYCHHC.ORG

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Continuing Professional Education

NYC HEALTH + HOSPITALS CME COMMITTEE

The NYC Health + Hospitals Continuing Education Committee members listed below review and support the provision of continuing medical educational credits for the learning activity and for the number of credit hours aforementioned are:

Members: Committee Members

Alfreda Weaver, MSN Ivelesse Mendez-Justiniano, MBAJanette Baxter John Maese, MD, Interim ChairpersonKatie Walker, RNOlivia Greene

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CME.NYCHHC.ORG

REGARDING TERMS, CONDITIONS, AND PURPOSES OF ANEDUCATIONAL GRANT

This Agreement is made between the NYC Health + Hospitals Continuing Medical Education Program hereinafter called NYC HEALTH + HOSPITALS CME Program and hereinafter called Company.

The Company agrees to provide to NYC Health + Hospitals CME Program a grant in support of an educational activity entitled on

The above Company agrees to provide the following: (indicate which option):☐ an unrestricted grant in the amount of $ ☐ a restricted grant to reimburse expenses for:

A. Speaker(s) All expenses Travel only Honorarium only

B. Support for catering functions (specify) in the amount of $

C. Other (e.g. brochure printing, mailing) in the amount of $

Conditions

1. Purpose of and Control over the Educational Activity

1.1 The activity shall be independent and non-promotional, focused on educational content, and free from commercial influence or bias. Information presented about commercial products shall be objective and based on scientific methods generally accepted in the medical community.

1.2 NYC Health + Hospitals CME Program shall maintain full control over the planning, content, quality, scientific integrity, implementation, and evaluation of the activity, and over the selection of speakers, moderators, authors, or other faculty for the activity.

1.3 The Company shall not engage in scripting, targeting points for emphasis, or other actions designed to influence the content of the activity.

2. Company Assistance in Planning, Production, and Marketing of the Activity

2.1 NYC Health + Hospitals CME Program may solicit assistance in the planning and production of the activity from the Company. That solicitation must be in writing. Acceptance by NYC Health + Hospitals CME Program of advice or services concerning speakers, moderators, authors, invitees or other educational matters, including content shall not be a condition of support for this activity. The Company shall not suggest speakers, moderators, or authors who are or were actively involved in promoting the company’s products or who have been the subject of complaints regarding misleading or biased presentations.

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CME.NYCHHC.ORG

2.2 The Company may provide services in support of the preparation of activity materials; however, these materials shall not, by their content or format, advance the specific proprietary interests of the Company.

2.3 If the Company offers to provide a presentation reporting results of scientific research the Company shall provide to NYC Health + Hospitals CME Program a detailed outline in order to confirm the scientific integrity of the presentations.

2.4 NYC Health + Hospitals CME Program must authorize dissemination of information about this activity by the Company, and any information must identify the activity as produced by NYC Health + Hospitals CME Program.

2.5 Invitations or mailing lists shall not be generated by the sales or marketing departments of the Company and shall not be generated or procured to reflect sales or marketing goals of the Company.

3. Disclosure

3.1 Meaningful disclosure shall be made to the activity audience of the following:

3.2 The Company’s funding of the activity, without reference to specific products.

3.3 Any significant relationship between NYC Health + Hospitals CME Program authors, presenters, or moderators and the Company.

3.4 Any significant financial or other relationship between authors, presenters, or moderators and the manufacturers of products or providers of services mentioned by the author, presenter, or moderator during the activity.

3.5 Whether any product mentioned during the activity is not labeled for the use under discussion or is still investigational.

3.6 Disclosure shall be made in writing in all instances when that is possible. Should disclosure occur verbally, such disclosure must be verified by written documentation in the activity file.

4. Scope and Presentation of the Activity

4.1 The title of the activity shall fairly and accurately represent the scope of the presentation.

4.2 The activity shall present discussion of multiple treatment options, and shall not focus on a single product, except when options are so limited as to preclude meaningful discussion.

4.3 Faculty shall be instructed to use generic names of products, or, if trade names are used, to use those of several companies.

4.4 Opportunity for meaningful discussion or questioning shall be provided during a live activity.

5. Conduct of the Company at Educational Presentations

5.1 Exhibit placement shall not be a condition of support for the activity.

5.2 No commercial promotional materials shall be displayed or distributed in the same room immediately before, during, or immediately after the educational activity.

5.3 Representatives of commercial supporters may not engage in sales activities while in the room where the educational activity takes place.

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5.4 Information about the Company’s product(s) presented in the activity may not be further disseminated after the initial presentation, by or at the behest of the Company in response to an unsolicited request or through an independent provider.

6. Social Events

6.1 Social events shall not compete with, nor take precedence over, the educational activity. This appropriateness of the social event is at the sole discretion of NYC HEALTH + HOSPITALS CME Program, shall have final authority in the scheduling and production of the social event.

6.2 The cost for the social event shall be modest.

7. Structure of Grant and Use of Funds

7.1 The educational grant shall be made payable to NYC HEALTH + HOSPITALS CME Program (Tax ID ) The Company shall pay no other funds to the director of activity, faculty, or others involved with the activity, personal expenses for non-faculty attendees.

7.2 Grant funds shall not be used to pay travel, lodging, registration fees, honoraria, or personal expenses for non-faculty attendees.

7.3 Grant funds may be used to permit medical students, residents, or fellows to attend the activity, as long as the selection of students, residents, or fellows who will receive the funds is made either by the academic or training institution, or by (Sponsor) with the full concurrence of the academic or training institution.

7.4 NYC HEALTH + HOSPITALS CME Program shall furnish the Company with a report concerning the

expenditure of grant funds if requested.

8. Regulatory Authority

8.1 NYC HEALTH + HOSPITALS CME Program and the Company agree to abide by all requirements of the American Osteopathic Association Guidelines for Relationships between Accredited Sponsors and Commercial Supporters of Continuing Medical Education.

AGREED

(Representative of Accredited CME Sponsor) Date

Typed or printed name

(Representative of Grantor Company) Date

Typed or printed name

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