Introduction

US/Canadian
Application

International
Application

Enduring Product
Application

Appendix A

CEC Information

ACCP Educational Enduring Product Application

The ACCP educational enduring product application form is designed to facilitate the planning, implementation, and evaluation that will comply with all ACCP Continuing Education Committee (CEC) standards as well as those of the Accreditation Council for Continuing Medical Education (ACCME). It also serves as a tool that will assist the ACCP Continuing Education Committee in providing effective review, planning, and logistical support.

In order for the CEC to review each proposal, all fields of the application are to be completed along with any supporting documentation. Both the application and the educational product should be completed in English. Supporting documentation should be sent to Ed Dellert, RN, MBA, Vice President, Educational Resources of the ACCP. Applicable fees will be associated with programs approved by the CEC for CME credit.

Download a sample of the ACCP Educational Enduring Product Application.
If this application is for joint sponsorship, view the ACCP Joint Sponsorship Fee Structure.

Note: The entire application will need to be completed in one session; it is not possible to save your entries and return to the application at a later time.

Professional Development Product Information

Product Title:

Product Description (include why ACCP needs this activity for its members):

Program agenda and number of CME hours being requested:

Keyword(s):

ACCP NetWork Affiliation:

NetWork Definition

Enduring products have a 1 year CME period. Extension of that period must be requested of the CEC.

Start Date:

Type of Product(s):

Print
	Monograph	Newsletter
	CHEST Journal CME
	Other:
CD-ROM/DVD
	From Live Course	Educational Resource
	Case Based Self-Study
	Other:
Web-Based
	From Live Course	Resource Tool Kit
	Live Web Cast	PDF Download Text
	Other:
Audio
	Audio Tape Only
	Other:

Action Requested
(check only one category, click here for explanation of the categories):

ACCP Sponsorship

ACCP Joint Sponsorship

Instructional Method to be used (check all that apply):

	Didactic Presentation		Interactive Multimedia
	Self-Study with Pre-Test		Self-Study with Post-Test

10.

Is financial support for production of the product being requested of ACCP?

	No	Yes
If yes, please submit a budget:
If no, who is financially supporting the product development?

11.

Proposed product pricing: $

12.

Number of copies of product to be distributed:

13.

Is any topic covered in this product still considered research or investigational?

	No		Yes (if yes, please explain below)

Target Audience
(Check the audiences for which this activity is primarily intended)

Specialty/Profession (check all that apply):

	Pulmonary Physicians		Cardiologists
	Advanced Practice Nurse		Respiratory Therapist
	Critical Care Physicians		Cardio-Thoracic Surgery
	Registered Nurse		Physician Assistant
	Fellows in Training		General Medicine
	Other:

Primary Target Location of Audience (check all that apply):

United States

Canada

International

Other:

Needs Assessment

What methods have been used to identify the need for or interest in this activity? Select at least two sources and provide a summary of the supporting documentation.

Expert Consensus
	Faculty perception
	Consensus of experts and ACCP committee members
Participant Feedback
	Survey of target audience
	Previous CME activity evaluation data
Research Findings
	Patient care audits/QI data
	Medical literature review
	Mortality/morbidity data
	Epidemiological data
	National clinical guidelines (e.g. ACCP, NIH, NCI, AHRQ)
	Database analysis (e.g. pharmaceutical, third-party insurance companies, peer-review organizations)
	Health Sciences library request data
Environmental Scan
	Institutional/Organizational Mandate
	Other
Summary of supporting documentation (this information could be emailed or faxed separately):

Identified Need(s):
After analyzing the needs assessment data identified above, list the specific need(s) that will be addressed by this educational activity (i.e., update or review of existing knowledge/skills; acquisition of new information, concepts, and/or skills; share new ideas to stimulate the development of knowledge/skills, etc.).

Objectives

Based upon the identified needs assessment, learning objectives for this educational activity should be identified in terms of knowledge, and how this knowledge cold impact physician practice and patient outcomes. Clearly stated learning objectives allow prospective participants to select ACCP educational activities that meet their educational needs. Establishing learning objectives not only helps participants, it also helps the faculty member guide their educational design, content, and conduct of a learning experience. This is an important principle supported by educational theory and practice.

Before listing your learning objectives below, make sure you consider the following suggestions:

Keep learning objectives brief and clear. The use of a clear, targeted verb provides a direction about the expectations of the faculty member with the prospective participant(s).
Keep learning objectives to specific statements of what prospective participants will be able to perform at the conclusion of the educational activity. In other words, all learning objectives should focus upon the prospective participant and indicate expectations of their performance or understanding of the educational content.
Designate the learning objective toward exactly what prospective participants need to do to demonstrate understanding of the educational activity. This could include references and resources that will be provided to the prospective participant.

1.
2.
3.
4.

Educational Grants (COMPLETE ONLY IF REQUESTING ACCP CME)
This activity must comply with the Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support.

Do you plan to solicit educational grants:

	No		Yes (if yes, please explain below)

Is there any potential financial conflict of interest of the faculty or the planning committee?

	No	Yes
(if yes, please explain below, and identify which faculty members have a potential conflict)

List of Proposed Faculty
The course director or co-director must be a FCCP of the ACCP for ACCP sponsored programs.

Course Director (Chair) Name:
Sub-topic title on program:
Address:
City:		State:
Country:		Zip Code:
Telephone:		Fax:
Email:

Course Co-Director Name:
Sub-topic title on program:
Address:
City:		State:
Country:		Zip Code:
Telephone:		Fax:
Email:

Faculty Name:
Sub-topic title on program:
Address:
City:		State:
Country:		Zip Code:
Telephone:		Fax:
Email:

Faculty Name:
Sub-topic title on program:
Address:
City:		State:
Country:		Zip Code:
Telephone:		Fax:
Email:

Faculty Name:
Sub-topic title on program:
Address:
City:		State:
Country:		Zip Code:
Telephone:		Fax:
Email:

Faculty Name:
Sub-topic title on program:
Address:
City:		State:
Country:		Zip Code:
Telephone:		Fax:
Email:

Faculty Name:
Sub-topic title on program:
Address:
City:		State:
Country:		Zip Code:
Telephone:		Fax:
Email:

Faculty Name:
Sub-topic title on program:
Address:
City:		State:
Country:		Zip Code:
Telephone:		Fax:
Email:

Contact Information

For correspondence regarding this application, please identify the primary contact person:

Applicant Name:
Address:
City:		State:
Country:		Zip Code:
Telephone:		Fax:
Email:

Please allow approximately 4 weeks for a review and recommendation of approval of your application. Supporting documentation (if applicable) should be sent to:

ATTN: Ed Dellert, RN, MBA, Vice President, Educational Resources
American College of Chest Physicians
3300 Dundee Road
Northbrook, IL 60062-2348
USA

Telephone: (847) 498-1400
Fax: (847) 498-5460
Email: edellert@chestnet.org




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