CME Activity Joint Providership Application and Agreement

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I. Activity

Thank you for considering Current Concepts Institute (CCI) as your accredited continuing education provider. Current Concepts Institute is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This accreditation grants CCI the ability to provide AMA PRA Category 1 Credits^TM , through Joint Providership, to non-accredited entities hosting non-commercial, physician-based educational events.

This form collects information to plan an accredited continuing education activity.

Completion of all sections and providing all supporting documents is required to meet accreditation requirements. For information, about accreditation requirements, please visit the Accreditation Council for Continuing Medical Education (ACCME) Accreditation Rules at Accreditation Council for Continuing Medical Education (ACCME) Accreditation Rules.

Organization Name

Activity Title*

Type of Activity*

Live (course, symposium, workshop, conference, series etc.)

Webinar – live activity

Hybrid (Live and webinar)

Other

Draft Agenda*

Upload a draft agenda. Topics, presenters & duration must be provided for live and webinars in order to estimate CME hours.
For reference, you may download and use the Agenda Worksheet here.

Max. file size: 1 GB.

Detailed Course Description of Activity (1000 characters maximum)*

II. Current Concepts Institute Mission Statement

The Current Concepts Institute (CCI) is dedicated to delivering contemporary continuing medical education (CME) to health care professionals with the ultimate goal of improving the quality of the care delivered to the public. These CME activities are designed to change the clinical competence or professional performance of the learner and/or improve patient outcomes independent of commercial bias. CCI develops, manages and provides accreditation to CME activities whose teachers are recognized clinical, surgical and scientific thought-leaders and that present evidence-based information to address professional practice gaps.

How does this activity align with the mission of CCI?*

Check all that apply.

Designed to assist physicians to gain competency and improve performance in health communications and professionalism.

Designed to assist in the dissemination of new medical knowledge from basic and applied research.

Collaborates on practice- and system-based quality improvement strategies to improve patient safety and to facilitate patient-centered care.

Designed to change physician behaviors to improve patient care.

Other

Other Mission Statement

III. Leadership, Administrative and Planning Committee

Activity Director*

Activity Director (AD), a person of an eligible company that has overall responsibility and knowledge for planning, developing, implementing and evaluating the content and logistics of this accredited continuing education activity.

First Name

Last Name

Institution

Phone

Activity Co-Director

Activity Co-Director, the individual who shares responsibility for planning the accredited continuing education activity. (optional)

First Name

Last Name

Institution

Phone

Administrative Coordinator*

Administrative Coordinator, the individual responsible for the operational and administrative support of this accredited continuing education activity.

First Name

Last Name

Institution

Phone

Planning Committee Member(s)*

Planning Committee, the individual(s) responsible for the design and implementation of this accredited continuing education activity.

First Name

Last Name

Institution

NOTE: Activity Director, Activity Co-Director, Administrative Coordinator and Planning Committee members will be required to complete and include a Disclosure of Relevant Financial Relationships form and be included on the Identification and Mitigation of Relevant Financial Relationships form if involved in the content planning of the activity and has a relevant financial relationship.

IV. Practice Gaps

Practice Gaps*

Identification of Professional Practice Gaps: The ACCME describes a professional practice gap as the difference between what the target audience does now vs. ideal or best practices. Please describe the professional practice gaps and educational needs that this educational activity will address. Based on the need/professional practice gap identified, what are the learning objectives of this activity? These objectives should be measurable and include the increased competence and/or improved performance and/or improved patient outcome that you wish to address in this activity, followed by the desired result.

Professional Practice Gap

Educational Need

This is a gap/need of: (Knowledge, Competence and/or Performance)

Learning Objective

Desired Result

Definitions:

Professional practice gap is defined as the difference between ACTUAL (what is) and IDEAL (what should be) in regards to performance and/or patient outcomes.
Educational need is defined as “the need for education on a specific topic identified by a gap in professional practice.”
Learning objectives are the take-home messages; what should the learner be able to accomplish after the activity? Objectives should bridge the gap between the identified need/gap and the desired result.
Desired results are what you expect the learner to do in his/her practice setting. How will the information presented impact the clinical practice and/or behavior of the learner? Indicate how this change could be reasonably measured.
Competence is defined as the ability to apply knowledge, skills, and judgment in practice (knowing how to do something).
Performance is defined as what one actually does, in practice.

V. Signature and Payment

Agreement:*

I attest that this accredited continuing education activity has been planned and is in compliance with the ACCME Standards for Integrity and Independence in Accredited Continuing Education. I will ensure the timely submission of all materials required for accreditation in the requested format(s). I have the authority to approve payment of all fees as indicated in this Agreement. Your application will be reviewed and next steps will be provided.

Acknowledged

Agreed by:*

Signature*

Date*

MM slash DD slash YYYY

Application Fee*

To process your application, payment is required.

Price:

Credit Card*

Card Details

Cardholder Name