Part II MOC – Application for Development Approval If you are human, leave this field blank. Title of Self-Assessment: * Activity Basics Medical Director - 1 * Name/Credentials Institutional/Organizational Affiliation * Institutional/Organizational Affiliation Email Address * Email Address Phone Number * Phone Number Is there a second medical director? * Yes No Medical Director - 2 Name/Credentials Institutional/Organizational Affiliation Institutional/Organizational Affiliation Email Address Email Address Phone Number Phone Number Desired Activity Presentation Date * (If this is not a live activity, please indicate the date you would like it to be launched) Will your target audience be Ohio pediatricians? * Yes No If no, please explain target audience: * Do you want this to be enduring material? * Yes No No Preference Activity Requirements Will the self-assessment cover one or more topics important to pediatrics? * Yes No If no, please explain which topic (or topics): * Will the Medical Director prepare the self-assessment? * Yes No See "Self-Assessment Question Requirements" for information on how to write proper questions. Names of Additional Physicians: * Self-Assessment Question Requirements -50 Questions for 20 points, 25 Questions for 10 points -To be valid, must be 4 or 5 option, single best answer, multiple choice questions -No "all of the above" responses, no multiple answers in a single choice (ex. D. A and C, E. B and C) Do you agree to have a periodic (at least once every three years) expert committee review that includes a review of content coverage, and relevance? * Yes, I agree No, I do not agree Does the activity permit participants to gauge strengths and weaknesses in their knowledge of the area under evaluation? * Yes No Please describe: * Do you have a planned ACCME-accredited CME provider for this activity? * Yes No Name of CME Provider: * Do you have the ability and willingness to share de-identified data with the ABP for purposes of analysis, activity evaluation, and standard setting? * Yes No Do you have any funding sources for this project/activity? * Yes No Please describe the funding sources: * Additional Information Relevant Pediatric Subspecialties (choose all that apply) * Adolescent Medicine All Specialties Child Abuse Pediatrics Developmental-Behavioral Pediatrics General Pediatrics Hospice and Palliative Medicine Hospitalist Medical Toxicology Neonatal-Perinatal Medicine Neurodevelopmental Disabilities Pediatric Cardiology Pediatric Critical Care Medicine Pediatric Emergency Medicine Pediatric Endocrinology Pediatric Gastroenterology Pediatric Hematology-Oncology Pediatric Infectious Diseases Pediatric Nephrology Pediatric Neurology Pediatric Pulmonology Pediatric Rheumatology Pediatric Transplant Hepatology Sleep Medicine Sports Medicine Please describe the activity in 300 words of less. This information will be listed on the ABP website. * Please provide completion criteria to be listed on the ABP Website. (i.e. must complete entire self-assessment with a score of at least 80%.) * Please attach any files that you would like to be reviewed with this application. Drop a file here or click to upload Choose File Maximum upload size: 134.22MB
