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ACCP United States and Canadian Educational Activity Application

The ACCP Continuing Medical Education (CME) application form for US and Canadian educational activities is designed to facilitate the planning, implementation, and evaluation of a CME activity that will comply with ACCP 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 (CEC) 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. Supporting documentation (if applicable) 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.

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.

A. US/Canadian Education Activity Information
1. Title of Education Activity:
 
2. Education Activity Description (include why ACCP needs this activity for its members):
 
3.
City: State:
4.
Start Date: End Date:
5. Program agenda topics including start and end times:
 
  CME/Instruction Hour(s) Requested:
6.
Keyword(s):
 
 
7.
ACCP NetWork Affiliation:
 
  NetWork Definition
8. Type of Course Activity (check all that apply):
 
Abstracts and Posters Audience Response Keypads (Interactive)
Case Discussion Lecture(s)
Panel Workshop(s)
Other:
9. Action Requested
(check only one category, click here for explanation of the categories):
 
Endorsement (no CME) ACCP Sponsorship
ACCP Joint Sponsorship    
10.
Estimated registration cost to ACCP members:
11.
Estimated Attendance:
  If the number of estimated attendance exceeds 1000, please specify:
12. Is any topic covered in this program still considered research or investigational?
(Topics which are still considered research or investigational may NOT be presented at activities approved for ACCP endorsement. Investigational or research topics may be presented at sponsored activities only.)
 
No Yes (if yes, please explain below)
B. Target Audience
(Check the audience 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:
  Target US/Canadian Audience Location (check all that apply):
 
Local Community State/Province
National North-East (US)
North-West (US) South-East (US)
South-West (US) Mid-West (US)
Atlantic (Canada) Prairies (Canada)
Central (Canada) Western (Canada)
Northern (Canada)    
Other:
 
C. Needs Assessment
1. 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):
2. 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.).
 
D. 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:

  1. 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).
  2. 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.
  3. 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.
E. 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.
1. Do you plan to solicit educational grants:
 
No Yes (if yes, please explain below)
2. 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)
F. List of Proposed Faculty
The course director or co-director must be a FCCP of the ACCP for ACCP sponsored programs.
1.
Course Director (Chair) Name:
Sub-topic title on program:
Address:
City: State:
Country: Zip Code:
Telephone: Fax:
Email:    
2.
Course Co-Director Name:
Sub-topic title on program:
Address:
City: State:
Country: Zip Code:
Telephone: Fax:
Email:    
3.
Faculty Name:
Sub-topic title on program:
Address:
City: State:
Country: Zip Code:
Telephone: Fax:
Email:    
4.
Faculty Name:
Sub-topic title on program:
Address:
City: State:
Country: Zip Code:
Telephone: Fax:
Email:    
5.
Faculty Name:
Sub-topic title on program:
Address:
City: State:
Country: Zip Code:
Telephone: Fax:
Email:    
6.
Faculty Name:
Sub-topic title on program:
Address:
City: State:
Country: Zip Code:
Telephone: Fax:
Email:    
7.
Faculty Name:
Sub-topic title on program:
Address:
City: State:
Country: Zip Code:
Telephone: Fax:
Email:    
8.
Faculty Name:
Sub-topic title on program:
Address:
City: State:
Country: Zip Code:
Telephone: Fax:
Email:    
G. Instructional Method
1. Instructional Method to be used (check all that apply):
 
Didactic presentation Panel discussion with Q/A
Pretest Posttest
Interactive Computer Response System
Demonstration of Equipment/Techniques
Other
2. Proposed technological equipment required (check all that apply):
 
Computer with projection Microphone
TV and VCR Satellite
Interactive Computer Response System
Other
H. Contact Information
  For correspondence regarding this application, please identify the primary contact person:
 
Applicant Name:
Address:
City: State:
Country: Zip Code:
Telephone: Fax:
Email:    
  Will this program be developed into an enduring product?
 
No Yes (please proceed to Appendix A after completing this form)

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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