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 Outcomes 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 Outcomes; 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 Outcomes.

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. 427, New York, NY 10013 or email a Microsoft Word copy of the application to Alfreda.weaver@nychhc.org or Gayle.daly@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.

Brochures, program announcements, and publications used to promote or to be distributed as part of 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 Choose an item. 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 Choose an item. 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

Facility / Organization: Click here to enter text.

Activity Title: Click here to enter text.

Activity Type: Choose an item.

Activity Date: Click here to enter a date.

Frequency of Activity: Choose an item.

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

Number of Presenters: Number of Planners: ______________

Application Checklist YES NO N/A

Completed Application ☐ ☐ ☐Signed Letter of Agreement for Joint Providers (If applicable) ☐ ☐ ☐Educational Grant Agreement (if applicable) ☐ ☐ ☐Copy of Announcement / Advertisement / Activity Brochure ☐ ☐ ☐Copy of Agenda ☐ ☐ ☐Calendar of Educational Activities ☐ ☐ ☐Completed & Signed Conflict of Interest Forms 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 Facility/Organization: Choose an item. Other: Click here to enter text.

III. Address of Educational Activity:

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

V. Type of Providership requested: Choose an item.

VI. Date(s) of educational activity: Attach calendar of scheduled educational activities

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

IX. Total Hours of Instruction: ________

X. 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. Program Learning Outcomes (minimum per hour of educational content)Click here to enter text.Click here to enter text.Click here to enter text.

IV. 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 Choose an item. for a maximum of Click here to enter text.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.

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 Choose an item. 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: Must include on the advertisement/marketing materials

New York City Health + Hospitals relies upon planners and faculty participants in its CME activities to provide educational information that is objective and free of bias. In this spirit and in accordance with the guidelines of MSSNY and the ACCME, all speakers and planners for CME activities must disclose any relevant financial relationships with commercial interests whose products, devices or services may be discussed in the content of a CME activity, that might be perceived as a real or apparent conflict of interest.

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:

V. Disclosure: A Financial Disclosure Form 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 a disclosure form 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 a disclosure form? ☐ 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 Outcomes Information – Form 15)

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FORM 3 NEEDS ASSESSMENT for the EDUCATIONAL ACTIVITY

I. Why is this learning session necessary?

1. What is the identified learning gap?

2. How was the gap in knowledge, competence, or performance measure determined or identified?Choose an item.Choose an item.*Define:

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

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

Competence / Performance / Pt. Outcome Learner Outcome

a.

b.

c.

d.

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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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.”

FORM 4 LEARNING OUTCOMES

I. State Learning Outcomes for the Program Activity.

Please ensure that the learning Outcomes 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.

3.

II. Educational Teaching Methods to Achieve Learning Outcomes

Indicate the educational methods that will be used to achieve aforementioned Outcomes 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: Please complete form 14 and 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:Please complete form 14 and 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: Please complete form 14 and 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.

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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)

I nstitute 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

Provide a list of faculty members and the activity 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

*Append the Curriculum Vitae or Resume and a signed disclosure form for each of the individuals

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NYC Health + Hospitals Continuing Professional Education Biographical and Conflict of Interest Form

Title of Educational Activity:

Education Activity Date:

Role in Educational Activity: (Check all that apply) ☐ Planning Committee Member☐ Faculty/Presenter/Author

☐ Content Expert☐ Other – Describe:     

Section 1: Demographic Data

Section 2: Expertise - Planning Committee

Planning committee member, select area of expertise specific to the educational activity listed above:☐ Physician Planner (responsible for ensuring adherence to ACCME/AMA Guidelines)☐ Nurse Planner (responsible for ensuring adherence to NJSNA Approval/ANCC Accreditation Criteria)☐ Social Work Planner (responsible for ensuring adherence to NYSED Board of Social Work Commissioner Regulations)☐ Licensed Mental Health Practitioner (responsible for ensuring adherence to NYSED Board for Mental Health Practitioner Commissioner Regulations) ☐ Other

Please describe expertise and years of training specific to the educational activity titled educational activity: (If the description of expertise does not provide adequate information, additional documentation may be requested.):

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Name:Physician: ☐ MD ☐ DO ☐ PsyD ☐ PhD ☐ DDSRegistered Nurse: ☐ AD ☐ BSN ☐ Masters ☐ DoctorateSocial Work: ☐ LMSW ☐ LCSW ☐ LCSW-R ☐ MSW Mental Health Practitioners: ☐ LCAT ☐ LMFT ☐ LMHC ☐ LPOther:Address:Phone Number:Email Address:Position/Title:

Section 3: Expertise - Presenter/Author/Content Expert

Discipline Expertise:Physician: ☐ Presenter ☐ Author ☐ Content Expert Registered Nurse: ☐ Presenter ☐ Author ☐ Content Expert Social Work: ☐ Presenter ☐ Author ☐ Content Expert Mental Health Practitioner L-CAT: ☐ Presenter ☐ Author ☐ Content Expert Other: ☐ Presenter ☐ Author ☐ Content Expert

Please describe expertise and years of training specific to the educational activity listed above.

☐ An "X" on this line identifies the expertise information the same as listed above.

Section 4: Conflict of Interest

The potential for conflicts of interest exists when an individual has the ability to control or influence the content of an educational activity and has a financial relationship with a commercial interest,* the products or services of which are pertinent to the content of the educational activity. The ‘Planner’ is responsible for evaluating the presence or absence of conflicts of interest and resolving any identified actual or potential conflicts of interest during the planning and implementation phases of an educational activity. If the ‘Planner’ has an actual or potential conflict of interest, he or she should recuse himself or herself from the role as ‘Planner’ for the educational activity. Commercial Interest Organizations are ineligible for approval or accreditation to provide continuing education.

All individuals who have the ability to control or influence the content of an educational activity must disclose all relevant relationships** with any commercial interest, including but not limited to members of the Planning Committee, speakers, presenters, authors, and/or content reviewers. Relevant relationships must be disclosed to the learners during the time when the relationship is in effect and for 12 months afterward. All information disclosed must be shared with the participants/learners prior to the start of the educational activity.

**Relevant relationships, as defined by ANCC, ACCME, NYSED, are relationships with a commercial interest if the products or services of the commercial interest are related to the content of the educational activity.

Relationships with any commercial interest of the individual’s spouse/partner may be relevant relationships and must be reported, evaluated, and resolved.

Evidence of a relevant relationship with a commercial interest may include but is not limited to receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (stock and stock options, excluding diversified mutual funds), grants, contracts, or other financial benefit directly or indirectly from the commercial interest.

Financial benefits may be associated with employment, management positions, independent contractor relationships, other contractual relationships, consulting, speaking, teaching, membership on an advisory committee or review panel, board membership, and other activities from which remuneration is received or expected from the commercial interest.

** All conflicts of interest, including potential ones, must be resolved prior to delivery of the continuing education activity.

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Is there an actual, potential or perceived conflict of interest for yourself or spouse/partner?☐ Yes ☐ No

If yes, complete the table below for all actual, potential or perceived conflicts of interest**: If No skip to Statement of Understanding section below.

Check all that apply Category Description☐ Salary☐ Royalty☐ Stock☐ Speakers

Bureau☐ Consultant☐ Other

Section 5: Conflict Resolution

Procedures used to resolve conflict of interest or potential bias if applicable for this activity: (Check all that apply)

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 educational 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).

Section 6: Statement of UnderstandingAn “X” in the box below serves as the electronic signature of the individual completing this Biographical/Conflict of Interest Form and attests to the accuracy of the information given above.

☐ Electronic Signature (Required) Date:

Planner/Expert/Presenter/Faculty/Author/Content Reviewer Name and Credentials

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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 post the activity:

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. Presenter Presentations6. Handouts / Educational Content

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: 17

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

Location:

Date(s): 1. List the indicators that establish the activity reached or will reach its desired outcome(s)

a.

b.

c.

Challenges:

Improvements:

2. The faculty was effective and achieved individual learning outcomes Choose an item.

3. Choose an item.Conflict of interest and financial relationship were fully disclosed Choose an item.

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

Choose an item.

5. Choose an item.50% of participants were members of the target population Choose an item.

6. Choose an item.Were participants satisfied with the delivery of the program? Choose an item.

7. Choose an item.Will you host this activity again? Choose an item.

8. Choose an item.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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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):

NamePlease 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.

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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 Outcomes, 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: __________________ Date: ________________ Print: __________________ Date: _________________

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Completed By: Name and Credentials Date

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NYC Health + HospitalsContinuing Medical Education – Educational Activity Planning Table

Title of Activity:

AMA PRA Category 1 CreditsTM: ____________________ Activity designed to enhance: Choose an item. Identified Gap in: Choose an item.

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

CONTENT (Topics)Provide an outline of the content

TIME FRAME Time required for content (minutes)

PRESENTER/AUTHOR List First Name, Last Name

TEACHING METHODS/LEARNER ENGAGEMENT STRATEGIES

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

A clear objective states what the learner will be able to do upon completion of the educational activity, in terms of behavioral change.  It identifies the desired outcome; whereas, the content for the activity is the information that supports achieving the objective, and not a

For every 60 minutes of content list 1 - 2 outcomes

Examples:PowerPoint Presentation-Lecture-Role Play-Q & A

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:

Outcomes: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)

NYC HEALTH + HOSPITALS

Written Disclosure/Accreditation and Objective Information

FORM 15

NYC HEALTH + HOSPITALS CONTINUING PROFESSIONAL EDUCATIONPARTICIPANT EVALUATION & ATTENDANCE ATTESTATION

TYPE: CE HRS ☐CME ☐ CEU ☐

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 Outcomes to the overall

goal & purpose of this learning activity? 1 2 3 4

2. To what extent were the following Outcomes 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

understandableDebriefing discussion engaging/organized

Small groups, role playing & assignments

a. 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

b. 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

c. 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 48. Instructor(s) establish/maintain appropriate teaching

strategies? 1 2 3 4

9. 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

Email: _______________________________________ Name: ________________________________

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 Outcomes to

the overall goal & purpose of this learning activity?

% % % %

2. To what extent were the following Outcomes 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 Subject Presentation orderly

and understandableDebriefing 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

CREATING A NEW PROFILE / UPDATING AN EXISTING PROFILE

CREATING 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.

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.

RETRIEVING EDUCATIONAL CREDITS OR CERTIFICATES1. 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.

IF YOU HAVE ANY QUESTIONS OR PROBLEMS CONTACT VIA EMAIL:

GAYLE DALY: GAYLE.DALY@NYCHHC.ORG

ALFREDA WEAVER: ALFREDA.WEAVER@NYCHHC.ORG

NYC HEALTH + HOSPITALS CME COMMITTEE

The members listed below review and support the provision of NYC H+H Continuing Professional Educational program.

Members: Steering Committee Members

Alfreda Weaver, MSN Continuing Professional Education DirectorJoann Liburd, Asst. Vice President Accreditation MemberIvelesse Mendez-Justiniano, Asst. Vice President Workforce Development MemberJanette Baxter, Sr. Director Risk Management MemberEric Wei, MD System Vice President MemberKatie Walker, Asst. Vice President IMSAL MemberGayle Daly, MA Sr. Executive Secretary Member

CME.NYCHHC.ORG

Attachments:

1. Agreement regarding terms, conditions, and purposes of an Educational grant

2. Agenda Template

3. Advertisement Template

4. Joint Provider Agreement

Agreement regarding terms, conditions, and purposes of an educational 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.

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.

CME.NYCHHC.ORG

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

3.4 Any relevant 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.

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

Date: Click here to enter a date. Activity Code: Choose an item.______

Activity Title: ________________________________________________

AGENDA

Start / End Time Speaker information / Activity

Educational Provider Name: Click here to enter text.Facility/Department: Click here to enter text.

Presents Choose an item.

Title: Click here to enter text.

Speaker: Click here to enter text.

Target Audience: Choose an item.

Goal: Click here to enter text.

Learning Outcomes: Click here to enter text. Click here to enter text. Click here to enter text.

Activity Completion Requirements:

Date: Click here to enter a date.

Time: Click here to enter text.

Location: Click here to enter text.

For registration information, please contact program coordinator (insert name of coordinator) at (insert telephone #) or (insert email address)

Physicians Nursing Social WorkRegistration Access: http://cme.nychhc.org Program Code: CPEM xx-xx| CPENxx.xx | CPES xx-xx

TURN OVER

Physician Accreditation StatementNYC Health + Hospitals is accredited by The Medical Society of the State of New York (MSSNY) to provide continuing medical education for physicians.

NYC Health + Hospitals designates this Choose an item. for a maximum of (insert credits hours) AMA PRA Category 1 Credit(s)™. Physicians should claim only credit commensurate with the extent of their participation in the activity.

CME Disclosure StatementsProgram Disclosure Statement:New York City Health + Hospitals relies upon planners and faculty participants in its CME activities to provide educational information that is objective and free of bias. In this spirit and in accordance with the guidelines of MSSNY and the ACCME, all speakers and planners for CME activities must disclose any relevant financial relationships with commercial interests whose products, devices or services may be discussed in the content of a CME activity, that might be perceived as a real or apparent conflict of interest.

Planners and Faculty/Presenters Statement with No Disclosures:The planners and faculty participants do not have any financial arrangements or affiliations with any commercial entities whose products, research or services may be discussed in these materials.

Planners and Faculty/Presenters Statement with No Disclosures:The following planner(s) and/or faculty have indicated a relationship with the following: (List Names)1.2.3.

Nursing Accreditation StatementNYC Health + Hospitals is an approved provider of continuing education by New Jersey State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. P# NYP264-11/16-19.

NYC Health + Hospitals designate this Choose an item. for continuing nursing education provider unit award of (insert credits hours) contact hours.

Social Work Accreditation StatementNYC Health + Hospitals Continuing Professional Education Program is recognized by the New York State Education Department State Board for Social Work as an approved provider of continuing education for licensed social workers #0074.

NYC Health + Hospitals designate this Choose an item. for a maximum of (insert credits hours) contact hours.

Physician Assistant Continuing EducationThe American Academy of Physician Assistants (AAPA) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit(s)™ from organizations accredited by ACCME or a recognized state medical society. Physician Assistants may receive a maximum of (same as physician credits hours) hours of Category 1 credit for completing this program.

Nurse Practitioner Continuing EducationThe American Academy of Nurse Practitioners Certification Program (AANPCP) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit(s)™ from organizations accredited by ACCME. Individuals are responsible for checking with the AANPCP for further guidelines.

This Choose an item. does not receive any financial support or in-kind contribution from commercial companies.

There is a participant fee of $________ associated with this activity.