Please complete this joint providership application as the initial step to determine viability of this initiative. CME staff will follow up within ten business days with further instructions. The following minimum lead time is required for submission: 3 months before a live, webinar, or hybrid activity up to 2 hours in duration; 6 months for an instructional design online activity; 12-18 months before a symposium. 

Please note all submissions must meet the AMA definition of CME content which is education which serves to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession. The content of CME is that body of knowledge and skills generally recognized and accepted by the profession as within the basic medical sciences, the discipline of clinical medicine, and the provision of health care to the public.
 

Activity Details

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Educational Needs

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State the educational opportunity or the difference between current practice and best practice on which this activity was based.
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Knowledge need (i.e., is there new technology or new information that physicians need to know more about) Competence need (i.e., are there tools or strategies available that might help learners apply what they should already know) Performance need (i.e. is there new technology or clinical information that necessitate learners assimilating new skills)

Designed to Change

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Provide evidence-based references (peer-reviewed journal articles links) that highlight the educational need (practice gap) and support the desired goal (what the activity is designed to change).

Activity Formats

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Competencies

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Planners/Faculty Info

  • Each planner/faculty must complete this disclosure form (click to link)
  • Communicate disclosure information collected to learners in a tangible way in advance of the activity (e.g., on the flyer, in the Final Program, or with some other written documentation). Baptist Health CME must retain a copy of this evidence.
  • Planners and faculty listed on this log who identify relevant relationships with ineligible companies will trigger the Baptist Health CME's resolution of conflict of interest (COI) process.

Commercial Support

Commercial support is financial or in-kind (e.g. products) contributions given by a ineligible company (any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients) which is used to pay all or part of the costs of a CME activity.
This does not include fees paid by vendors for an exhibit booth or companies which pay corporate sponsorships in exchange for ads, booth space or other tangible benefits.

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Please check each attestation

Exhibitor and Corporate Support    

Standard 2 of the Standards for Integrity and Independence in Accredited Continuing Education specifies that accredited continuing education must protect learners from commercial bias and marketing.
1. The accredited provider must ensure that 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.
2. Accredited education must be free of marketing or sales of products or services. Faculty must not actively promote or sell products or services that serve their professional or financial interests during accredited education.
3. The accredited provider must not share the names or contact information of learners with any ineligible company (any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients) or its agents without the explicit consent of the individual learner.

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How will you determine the effectiveness of your CME activity?

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I hereby certify that the information provided in this application is complete and accurate to the best of my knowledge. In the event any information changes or the CME Activity descriptions are no longer accurate, I agree to notify Baptist Health CME at MarieV@BaptistHealth.net. In addition, I agree that our organization will fulfill the expectations and obligations as set forth by Baptist Health CME, including the submission of requested compliance documentation and payment of all fees within the time frames specified and understanding that the failure to do so can result in the assessment of a late fee or termination of services.
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Please type your First and Last Name
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