RSS CME Application
Please complete this application if your event is a going to have multiple sessions. If you have any questions as to which application you should complete please call Laurie Militello, (585) 271-1307.
Organization
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Department (if applicable)
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Activity Director
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Activity Director Email
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Activity Director Phone
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Administrative Contact (if applicable)
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Administrative Contact Email
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Proposed Activity Title
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Proposed Activity Location
Include Venue, City, State
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Proposed Series Start Date
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Proposed Number of Hours of Program Content per Session
This should only include hours of learning.
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Type of RSS
Required
Please list the names of all individuals that have control over the content of the series, and indicate their role next to their name.
This should include all planning committee members, speakers, presenters, moderators, reviewers for this event.
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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.
Required
Why does your target audience need to learn about this topic?
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What sources were used to identify the current state of knowledge, competence, or performance?
Each source checked must be cited and summarized below.
Required
Please cite and summarize the sources checked above.
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Designed 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.
Your answer
What sources were used to identify the ideal/desired state of knowledge, competence, or performance?
Each source checked must be cited and summarized below.
Required
Please cite and summarize the sources checked above.
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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.
Your answer
Please describe your target audience and explain how the content pertains to this target audience?
Your answer
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?
Required
What is the rationale for using the format(s) selected above?
Your answer
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 this series?
Competencies and Attributes are national goals for physicians associated with targeted specialties that should be addressed whenever possible in planning CME.
Required
What specific content in this activity address the selected competencies?
Your answer
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 commerical support?
Only if you selected yes to the above question.
Your answer
Will you have exhibits/vendors during this series?
If you selected "No" to the above 2 questions: How will your series be funded?
Your answer
Evaluation & Follow - Up
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 evaluate this series?
Please refer to the description in order to answer this question correctly, to avoid revision.
Your answer
Non-Education Strategies
Criteria 17: The provider utilizes non-education strategies to enhance change as an adjunct to its activities/educational interventions (e.g., reminders, patient feedback).
Will you be using a non-education strategies to supplement your series?
What non-education strategy will you be using?
Only if you selected yes to the question above.
Barrier 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?
Your answer
Building Bridges with Stakeholders
Criteria 20:
Are there other initiatives within your organization working on this issue?
If yes, please name initiative or department:
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How have you collaborated?
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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 collaborate with the Rochester Academy of Medicine CME Committee to ensure that the planning, implementation, and follow-up necessary for the proposed CME activity are consistent with the MSSNY and ACCME Essential Areas, Elements, Criteria, Policies, and Standards for Commercial Support (SCS).

First & Last Name
Your answer
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