CME Application - Ohio AAP

Activity Title:

Ohio AAP Program Manager:

Ohio AAP Program Manager Email:

Activity Medical Director:

Activity Format:

Live Activity

Enduring Activity

Journal Club Activity

Live Activity Date:

Enduring Activity Start and End Dates (Up to 12 months):

Live Activity Location:

How many credits will this activity contain? (CME & MOC Part 2 must have equal points)

Is MOC Part 2 Requested?

Yes

No

Please select the educational need(s) that apply to this activity:

Knowledge

Competence

Performance

Please provide a summary of the activity for sharing with reviewers and program marketing in 150 words or less.

State the professional practice gap(s) of your learners on which the activity was based.

What areas of professional practice need to be improved?

State the educational need(s) that you determined to be the cause of the professional practice gap(s).

What do participants need to be taught to improve the areas identified as professional practice gaps?

Explain what competence, performance, or patient outcome this activity was designed to change.

What will participants be able to do after the education that will help address the identified professional practice gaps?

In addition to identifying the educational format(s) that you have chosen, explain why these formats are appropriate for the setting, objectives, and desired results of this activity.

Select the desirable physician attribute(s) this activity addresses.

Describe the strategies you used to obtain data or information about changes achieved in learners’ competence or performance or patient outcomes as a result of their participation in this activity, including, for example, the questions you asked the learner about changes in competence or performance or other change data such as quality improvement or patient outcomes.

Will this activity include a specific focus on representation and/or use the Ohio AAP's Speaker Toolkit in content creation?

The activity includes a specific representation focus

The activity team will use the Speaker Toolkit in content creation

Additional details or commentsAdditional details or comments

Learning Objectives

Please provide at least two Learning Objectives per hour of credit requested, and use a separate text box for each objective. Please phrase objectives with action verbs whenever possible; details and samples of objective verbs are available at: https://tips.uark.edu/using-blooms-taxonomy/

Objective 1

Objective 2

Objective 3

Objective 4

Planners and Speakers

Please list the names and emails of all individuals that have control of the content and their role; if more than 6 individuals are involved, please send the name and email of all individuals to Marc Driscoll at mdriscoll @ohioaap.org. Each of these individuals will receive an email with instructions to complete the required Conflict of Interest form at: https://outcomes.ohioaap.org/coiform/

Planner or Speaker 1 Name

Planner or Speaker 1 Email

Planner or Speaker 2 Name

Planner or Speaker 2 Email

Planner or Speaker 3 Name

Planner or Speaker 3 Email

Planner or Speaker 4 Name

Planner or Speaker 4 Email

Planner or Speaker 5 Name

Planner or Speaker 5 Email

Planner or Speaker 6 Name

Planner or Speaker 6 Email

Planner or Speaker 7 Name

Planner or Speaker 7 Email

Planner or Speaker 8 Name

Planner or Speaker 8 Email

Planner or Speaker 9 Name

Planner or Speaker 9 Email

Planner or Speaker 10 Name

Planner or Speaker 10 Email

Enduring and/or MOC Part II Activity Details

What learning assessment tool(s) will you use?

Please include what the passing standard is for the learner assessment mechanism.

Please include a description of the process by which feedback will be provided to learners, and if credit has been awarded, verification that the learner(s) successfully met the passing standard for the activity.

Commercial Support and Exhibit Confirmations

All decisions related to the planning, faculty selection, delivery, and evaluation of accredited education are made without any influence or involvement from the owners and employees of an ineligible company.

Yes

No

The activity is free of marketing or sales of products or services. Faculty will not actively promote or sell products or services that serve their professional or financial interests during accredited education.

Yes

No

All recommendations for patient care in accredited continuing education must be based on current science, evidence, and clinical reasoning, while giving a fair and balanced view of diagnostic and therapeutic options.

Yes

No

Will you be seeking commercial support?

Yes

No

From which companies are you seeking commercial support?

Will you have exhibits/vendors?

Yes

No