Proposal Form for a Continuing Education Course[Word - 362 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 Sources[Word - 292 KB]
CE activities are developed in response to, and with consideration for, the unique educational needs of the target audience. Each educational activity is developed to solve a problem in practice, this is the needs assessment and documents how and why the topics for the program were chosen; the process of identifying and analyzing data that reflect the need for a CE activity. The data could result from learner surveys, evaluations from previous CE activities, needed health outcomes, identified new skills, etc. Needs assessment data provide the basis for developing learner objectives for the CE activity.
Agenda - include a program agenda indicating start and end times for all presentations, breaks, and lunches, etc.
Learning Outcomes/Objectives using the Educational Planning Table[Word - 27 KB]
after the need is determined, specify what learners need to do differently in order to improve their practice (the outcomes/objectives). These statements describe knowledge, skills, and/or practice changes that should occur upon successful completion of the educational activity. Specific objectives for the learning activity are developed collaboratively by the planners and faculty/presenters/authors (if applicable) and must relate to the purpose of the activity. Then, choose the most effective format that will help accomplish these learner objectives.
Faculty List with Disclosure Statement - selected faculty should be experts in the subject matter the activity covers. The results of the disclosure process must be added.
Speaker Letter -Communication of expectations will help make the learning intervention effective.
Speaker & Planner Disclosure /Biographic Data Form[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[Word - 362 KB]
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.
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 are no monies appropriated other than the CE fees. This is required 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.
Course Attendance Summary[Word - 55 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.
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.