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Required Forms for a Regularly Scheduled Series

PRE-ACTIVITY

  • Proposal Form for a Regularly Scheduled Series (RSS) [Word - 365 KB]
    All CE activities must meet our accrediting bodies' criteria to be eligible for CE. This form is used to initiate the educational design process for a CE activity which includes a description of the activity, the purpose and desired goals and identifies the planners of the activity.
  • Needs Assessment Form and Narrative [Word - 292 KB]
    CE activities are developed in response to, and with consideration for, the unique educational needs of the target audience. For an RSS activity, this form is used to describe a broad overview of why you are planning the educational series, (i.e. grand rounds, CE lecture series, tumor board, or journal club). Include the analyzed evidenced based data obtained to identify the need for a CE activity. Such data could result from learner surveys, evaluations from previous CE activities, needed health outcomes, identified new skills, literature review of best practices, etc.
  • Documentation of RSS Form - This is a "mini" needs assessment for each presentation provided. Each educational activity is developed to solve a problem in practice. Explain how and why the topics were chosen and specify what learners will need to do differently in order to improve their practice (the outcomes/objectives). The outcomes describe knowledge, skills, and/or practice changes that should occur upon successful completion of the educational activity. Then, choose the most effective format that will help accomplish these learner objectives. This form is not readily accessible but will be sent to you upon receipt of the RSS proposal form.
  • Topics/Dates/Speakers/Objectives of first 3 presentations (if available)
  • Speaker & Planner Disclosure /Biographic Data Forms [Word - 559 KB]
    To award credit, all those in a position to control the content of an educational activity must disclose all relevant financial interest. "Relevant financial relationships" are defined as financial relationships in any amount occurring within the past 12 months that create a conflict of interest. If an individual refuses to complete the disclosure form, s/he will be disqualified from being a planning committee member or speaker, and cannot have control of, or responsibility for, the development, management, presentation or evaluation of the activity. Signed disclosure forms must be provided to coordinator at least one week in advance for review of any potential conflict of interest. If the review cannot be accomplished before the activity, the presentation cannot be designated for CE credit.
  • Draft Publicity/Marketing/Promotional Material- prior to promoting the activity, all publicity materials are reviewed for accurate accreditation language. No statement such as "CE credit applied for" or "credit pending" may be used.
  • Presentation Evaluation - all activities must be evaluated for effectiveness including the changes learners intend to make in their practice as a result of participating in the activity. In addition to immediate feedback from participants, we encourage outcomes (or follow-up) data be measured for impact of learning. The planners should analyze the raw data and on an annual basis, submit an overall evaluation summary.
  • Financial Revenue-Expense Worksheet, if applicable - a report of anticipated income and expenditures, including the sources of expected financial support. A budget is not required if the activity is solely supported by the agency and there is no monies appropriated other than the CE fees. To identify and appropriately manage any commercial support if any.
    Note: The IHS CSC does not accept financial or in-kind support from commercial interests.

POST-ACTIVITY

  • RSS Sign In Sheet [Word - 66 KB]
    Used to verify attendance for participants who wish to claim credit for attending the activity.
  • Overall Evaluation Summary [Word - 67 KB]
    A summary of the planning committee's analysis of the evaluation data and the conclusions reached about its effectiveness. An annual summary is required and is also needed to renew or close RSS activities.
  • Physician Teaching Credit Request Form [Word - 282 KB]
    Physician (MD or DO) faculty may be awarded credit based on a 2-to-1 ratio to presentation time. For example, faculty may be awarded 2 AMA PRA Category 1 AMA PRA Category 1 Credits™ for a 1-hour presentation that was designated for AMA PRA Category 1 Credit™. Credit may only be claimed once for an original presentation; credit may not be claimed for subsequent presentations of the same material. Physician faculty may not claim credit as a participant for their own presentations; however, they may claim credit for other segments they attend as a participant at a certified live activity.