CME Activity Application CME Activity Application 2020 Activity Title * Activity Director * Activity Director Email * Ohio AAP Staff Member * Proposed Activity Date * MOC Part II requested? * Yes No Please select one of the following: * Live Activity Enduring Activity Live Regularly Scheduled Series (RSS) Enduring Regularly Schedule Series (RSS) Journal Based CME Test Item Writing Manuscript Review If you choose Live Activity, please select one of the following Course Internet Live Course Regularly Scheduled Series (RSS) Learning from Teaching Live Webcast Proposed Activity Location * How many credits will this activity contain? CME and MOC Part II must be equal in points. * Please list the names of all individuals that have control over the content of the activity, and indicate their role next to their name. * Please have all individuals listed in the box complete a Disclosure Form at the following link: https://www.surveymonkey.com/r/OhioAAPCOI Please provide a description of the project, including topics to be addressed, evaluation method, education modality, and overall goals, in 150 words or less for CME reviewers. * How will you be evaluating this course? Please refer to the description in order to answer this question correctly, to avoid revision. Please be specific to your course & evaluation. I will send a 6 month post evaluation to attendees to assess change in practice based on the learning objectives of the course. I will send a 6 month post evaluation to attendees to assess change in practice based on the learning objectives of the course. MOC Part II Only Click here to view Evaluation/Assessment Examples. Learner Assessment Tool: Please select one of the following: Learner Assessment Tool: Please select one of the following: ----- Case Discussion Written responses Audience response system Quiz Table-top exercise Simulation Review of manuscript Writing test items Learning from teaching 1.Learner assessment description, please include what the passing standard is for the learner assessment mechanism. Examples are multiple choice question test, passing score, small group discussion, observation, and feedback during simulation: 3. A description of the process by which feedback will be provided to learners; and if credit has been awarded, verification that the learner(s) successfully met the passing standard for the activity. Feedback to the participant must include learner results with rationale for correct answers or attainment of applicable skill(s) and include relevant citations where appropriate. Funding Criteria 7: The provider develops activities/educational interventions independent of commercial interests. (SCS 1, 2, and 6). It is the policy of the Rochester Academy of Medicine (RAM) to ensure balance, independence, objectivity, and scientific rigor in all educational activities. Will you be seeking commercial support for this series? Yes No Unsure From which companies are you seeking commercial support? Only if you selected yes to the above question. Will you have exhibits/vendors during this series? Yes No Unsure If you are human, leave this field blank.
