Regularly Scheduled Series (RSS) CME for MOC Activity Application
ACCME defines a regularly scheduled series (RSS) as a live activity planned as a series with multiple, ongoing sessions, e.g., offered weekly, monthly, or quarterly.

If you have any questions as to which application you should complete please call Sue Layton 585-271-1307.
Sign in to Google to save your progress. Learn more
Organization *
Department
(if applicable)
Activity Director *
First and Last Name
Activity Director Email *
Activity Director Phone *
Administrative Contact
(if applicable)
Administrative Contact Email
Administrative Contact Phone
Proposed Activity Title *
Proposed Activity Start Date *
MM
/
DD
/
YYYY
Proposed Activity End Date *
MM
/
DD
/
YYYY
Proposed Activity Location *
Proposed Number of Hours of Program Content Per Session
 *
Round to nearest quarter hour of learning.
Proposed Maximum Number of Hours of Program Content 
This is the maximum number of CME/MOC points a learner could earn from the entire series, not per session (ex. 52 credits for 52 weeks)
Please indicate the type of Continuous Certification credit for which you are registering this activity: *
Required
Type of RSS: *
Required
Please list the names of all individuals that have control over the content of the activity, and indicate their role next to their name. *
Include all planning committee members, panelists, speakers, presenters, moderators, and reviewers
Professional Practice Gap
Criteria 2: The provider incorporates into CME activities the educational needs that underlie the professional practice gaps of their own learners.
 
Knowledge - A gap in learner knowledge.  

Competence - A gap in the ability to apply knowledge.  

Performance - A gap in the actual application of knowledge to practice.
Select the underlying professional practice gap (PPG) *
Why does your target audience need to learn about this topic? *
Include evidence for the PPG.
What sources were used to identify the current state of knowledge, competence, or performance? *
Each source checked must be cited or summarized below.
Required
Please cite & summarize the sources checked above. *
The full text of your citations need to be sent to: cmeraom@gmail.com
Design to Change
Criteria 3: The provider generates activities/educational interventions that are designed to change competence, performance, or patient outcomes as described in its mission statement.
Your series will be designed to change *
Required
Describe the ideal/desired state of knowledge, competence or performance: *
What sources were used to identify the ideal/desired state of knowledge, competence, or performance? *
Each source checked MUST be cited or summarized below.
Required
Please cite the sources checked above. *
The full text of these citations need to be sent to cmeraom@gmail.com
What are the learning objectives for this series? *
The ultimate goal of your activity must directly relate to the PPG previously selected. In addition, all learning objectives listed must be evaluated. Therefore, plan on incorporating your learning objectives into your method of evaluation of the activity.  
Examples: Knowledge/competence - "To enable learners to recognize  current diagnostics and treatment methods".  Performance - "To increase the utilization of current evidence-based diagnostics and treatment methods".  Patient Outcomes - "To decrease infection rates and improve patient satisfaction".
Please describe your target audience. *
Explain how the content pertains to this target audience? *
Please be specific.
Educational Format
Criteria 5: The provider chooses educational formats for activities/interventions that are appropriate for the setting, objectives, and desired results of the activity.
What is the educational format of the series? *
Please all that apply.
Required
What is the rationale for using the format selected above? *
Please be specific.
Evaluation
Criteria 11: The provider analyzes changes in learners (competence, performance, or patient outcomes) achieved as a result of the overall program's activities/educational interventions.

Criteria 12: The provider gathers data or information and conducts a program-based analysis on the degree to which the CME mission of the provider has been met through the conduct of CME activities/educational interventions.

All CME activities must be evaluated to assess the extent to which the program has achieved the change in competence, performance, or patient outcomes. Your method of evaluation will depend upon the PPG you selected.

Examples:
Competence - Physician self-report of intended application of new knowledge to their practice.

Performance - Physician self-report on the application of the new knowledge to their practice.

Patient Outcomes - Data, such as re-admittance rates, compared prior to the activity and 6 months later.
How will you be evaluating this series? *
Please refer to the description in order to answer this question correctly, to avoid revision. Please be specific to your course & evaluation.
Non-Education Strategies
Criteria 17: The provider utilizes non-education strategies to enhance as an adjunct to its activities/educational interventions (e.g., reminders, patient feeback).
Will you be using non-education strategies to supplement your series?
Clear selection
What non-education strategy will you be using?
Clear selection
Complete this question only if the series is being registered as a Self-Assessment (Accredited CME with Evaluation and Feedback).

Briefly describe the minimum participation threshold (ex. score, correct written or shared responses, etc.) for the learner to earn Continuous Certification credit.  

Note: Learners must score a 75% or higher for the Self- Assessment to count.  There are no minimum number of questions. Repeated attempts are allowed.
Complete this question only if the series is being registered as Self-Assessment (Accredited CME with Evaluation and Feedback).

Briefly describe the process by which feedback will be provided to learners.
Physician Competencies & Attributes
Criteria 6: The provider develops activities/educational interventions in the context of desirable physician attributes [eg, Institute of Medicine (IOM) competencies, Accreditation Council for Graduate Medical Education (ACGME) Competencies].
What ACGME, ABMS or IOM competencies are associated with the series? *
Competencies and Attributes are national goals for physicians associated with targeted specialties that should be addressed in CME.
Required
What specific content in the series address the selected competencies? *
Which ABS practice area(s) are associated with the series? *
Required
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? *
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? *
If you selected "No" to the above 2 questions: How will this series be funded?
Include all sources of funding.
Will there be a Fee to Register for this Series?
Clear selection
Barriers to Change
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.
What could block the learner from implementing the new learned behaviors, strategies, or skills taught? *
Required
Are there any ways to remove, overcome, or address these barriers? *
Building Bridges with Stakeholders
Criteria 20: The provider builds bridges with other stakeholders through collaboration and cooperation.
Are there other initiatives within your organization working on this issue? *
If yes, please name initiative or department:
How have you collaborated?
Electronic Signature
The undersigned hereby agrees to use an electronic signature in lieu of a paper-based signature, understanding that electronic signatures are legally binding in the United States and in other countries.

I HEREBY CERTIFY THAT:

1. This application was completed entirely and accurately, and I attest to the validity of the information contained within.

2. I understand my responsibilities as the non-accredited educational partner.

3. I agree to compliance with ACCME's CME for MOC Program Guide and ABS requirements.

4. I agree to collect the required individual learner completion data and RAoM will submit it via PARS.

5. I agree to abide by ABS and ACCME requirements for use of the data.

6. I agree to allow ACCME to publish data about the activity on ACCME's website.

7. I agree to collaborate with the Rochester Academy of Medicine CE Committee to ensure that the planning, implementation, and follow-up necessary for the proposed CME activity are consistent with the MSSNY and ACCME Standards for Integrity and Independence in Accredited Continuing Education, and MOC requirements as described in the CME Maintenance of Certification Program Guide.
First & Last Name *
Date *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms