| Course Name | Breastfeeding |
|---|---|
| Administrative intake Information | |
| Administrative intake information | |
| What type of activity are you seeking accreditation for? | Section 1: Group Learning Program |
| Section 1: Group Learning Program | |
| Section 3: Self-assessment Program | |
| Section 3: Simulation-based Activity | |
| Date of application | |
| Event location (insert city and province) | |
| Activity start date | |
| Activity end date | |
| Title of learning activity (as it will appear on the certificate of attendance) | |
| Website Link to registration or website promotion (or insert ‘not applicable’) | |
| Delivery method of learning activity | |
| How many times will this activity be held in a year? | |
| Has this activity been previously accredited? | |
| Has this activity been submitted to another CPD Accreditor? i.e., RCPSC, CFPC, CNA, CCCEP | |
| Please name CPD Accreditor | |
| Has this activity been rejected by another CPD Accreditor? | |
| Please elaborate | |
| Do you want this event posted on the Royal College (RCPSC) website? | |
| Anticipated number of participants: | |
| aii: Reviewer Checklist | |
| Physician organization information | |
| Physician organization requesting accreditation | |
| Name of physician organization (as specified by the tool tip) | |
| Website address (or insert 'not applicable') | |
| Chair of the Scientific Planning Committee | |
| First name | |
| Last name | |
| Address | |
| Phone number | |
| Contact information for main point-of-contact for participants | |
| First name | |
| Last name | |
| Address | |
| Phone number | |
| Organizations co-developing the activity. Do not include sponsors as co-developers. | |
| Name | |
| Is the co-developing organization a physician organization? (Yes/ No) | |
| Phone number | |
| Website address | |
| The physician organization agrees to maintain attendance records for 5 years. Do you comply? | |
| Was the content developed by the Scientific Planning Committee? | |
| Who developed the content? | |
| Does this activity have SPC that includes representatives of the target audience? | |
| Explain how you will obtain the input of the missing members of the target audience | |
| The SPC may consider data or advice from all sources but must ensure that decision-making related to the following CPD program elements is under its exclusive control. Do you comply? | |
| Representatives of a sponsor or any organization hired by a sponsor cannot participate in decisions related to CPD program elements. Do you comply? | |
| List Scientific Planning Committee members (One must be a RCPSC member) | |
| Name | |
| Credentials | |
| How does the individual represent target audience? | |
| Is the individual a member of the developing or co-developing physician organization? | |
| Who is the intended primary target audience of the activity? | |
| poi: Reviewer Checklist | |
| Program Details | |
| Intended Primary Target Audience and Learning Objectives | |
| Which assessment strategies were used to identify the PERCEIVED learning needs of the target audience? Indicate all that apply | |
| Consultation with Scientific Planning Committee Members | |
| Surveys | |
| Questionnaires | |
| Focus Groups | |
| Direct request from target audience. | |
| Others | |
| List others | |
| Please attach artifact of perceived learning needs assessment strategy. Attach one artifact per selected option | |
| Please share link to Sharepoint folder with artifact | |
| Attach minutes or list of topics of consultation with Scientific Planning Committee members | |
| Attach survey results | |
| Attach questionnaire results | |
| Attach focus group summary results | |
| Attach summary results of direct requests from target audience | |
| Which assessment strategies were used to identify the UNPERCEIVED learning needs of the target audience? Indicate all that apply | |
| Self-assessment tests | |
| Direct observation of practice performance | |
| Provincial databases | |
| Chart audits | |
| Practice audits | |
| Incident reports | |
| Chart-stimulated recall Interviews | |
| Quality assurance data from clinics, PCNs, hospitals, regions | |
| Published literature (RCT, cohort studies) | |
| Clinical Practice Guidelines list | |
| Performance-assessment with Standardized patients | |
| Electronic Medical Record data | |
| Others | |
| List others | |
| Please attach artifact of perceived learning needs assessment strategy. Attach one artifact per selected option | |
| Please share link to Sharepoint folder with artifact | |
| Attach self-assessment test summary results | |
| Attach documentation for direct observation of practice performance | |
| Attach list of references for published literature | |
| Attach list of references for clinical practice guidelines | |
| Which learning needs or gap(s) in knowledge, attitudes, skills, or performance of the intended target audience did the scientific planning committee identify for this activity? | |
| Did the Scientific Planning Committee use the needs of the target audience to develop the activity overall learning objectives? | |
| Yes | |
| No | |
| Did the scientific planning committee share the needs assessment results with the speaker who is responsible for developing the overall learning objectives. | |
| Yes | |
| No | |
| What other methods were used to develop overall learning objectives? | |
| How were the identified needs of the target audience used to develop the session learning objectives? Select all that apply | |
| The scientific planning committee shared the needs assessment results with the speakers who are responsible for developing the session learning objectives. | |
| The scientific planning committee used the needs assessment results to define the session learning objectives for the speakers. | |
| Do the overall Learning Objectives clearly describe the intent of the educational activity, and are written from the perspective of the learner, and express the expected outcomes determined by the SPC and faculty? | |
| Yes | |
| No | |
| Does the program contain individual sessions or modules? | |
| Yes | |
| No | |
| Does your program have sessions or modules? | |
| Yes | |
| No | |
| Do the Session or Module Learning Objectives clearly describe the intent of the educational activity, and are written from the perspective of the learner, and express the expected outcomes determined by the SPC and faculty? | |
| Yes | |
| No | |
| Are the overall Learning objectives available to participants prior to registration? | |
| Yes | |
| No | |
| Please explain | |
| Indicate where Learning Objectives are listed | |
| Website | |
| Brochure/Flyer | |
| Email/Letter | |
| Include link to each place where Learning Objectives are listed | |
| Attach a pdf for each place where Learning Objectives are listed | |
| Are the learning objectives included in the evaluation to participants? | |
| Yes | |
| No | |
| Which CanMEDS Role(s) relevant to this activity? Select all that apply | |
| Medical Expert | |
| Leader | |
| Professional | |
| Communicator | |
| Health Advocate | |
| Scholar | |
| Collaborator | |
| Which learning formats/methods are used to support the following: the perceived and/or unperceived educational needs, meet the stated learning objectives, and address CanMEDS roles | |
| Which learning methods were selected to incorporate a minimum of 25% interactivity? | |
| Does the program and/or brochure identify the opportunity for interactive learning? | |
| Yes | |
| No | |
| Explain | |
| Those developing or delivering the educational content were informed of the following | |
| The identified needs of the target audience | |
| The need to ensure that the content and/or materials presented provide (where applicable) a balanced view across all relevant options related to the content area | |
| The intended overall learning objectives for the activity | |
| Ensuring that the description of therapeutic options utilize generic names (or both generic and trade names) and not reflect exclusivity and branding | |
| Email or letter to speaker is attached | |
| Please add a link to a Sharepoint folder that contains the email or letter to speaker | |
| loa: Reviewer Checklist | |
| Evaluation | |
| How will the overall activity and individual sessions or modules be evaluated by participants? | |
| Evaluation survey | |
| Other methods (e.g., participant focus group, individual participant interviews) | |
| Please add Sharepoint link to folder with the evaluation survey | |
| Please specify | |
| Please add Sharepoint link to folder with the supporting documentation | |
| Select each the following that are included in the evaluation | |
| The program met the overall learning objectives | |
| The session or module met the session learning objective | |
| Was the overall program balanced and free of commercial or other inappropriate bias, and if “No” please comment | |
| Provide opportunities for participants to identify the potential impact of the CPD activity for their practice. Example: Describe at least 2 ways you intend to change your practice as a result of attending this course or program. | |
| The program incorporated 25% interactivity | |
| Does the assessment strategy intend to use post-course reinforcement activities and to reinforce changes in knowledge, skills or attitudes of learners, and support development of a learning plan? | |
| Yes | |
| Not applicable | |
| Please describe | |
| Does the assessment strategy intend to use post-course quality improvement activities to measure improved health care outcomes, or improved patient performance? | |
| Please describe | |
| Not applicable | |
| Yes | |
| Do participants receive feedback related to their learning, describe the tools or strategies used? | |
| Yes | |
| Not applicable | |
| Please describe | |
| eval: Reviewer Checklist | |
| Self- Assessment Program | |
| Does this course have online modules | |
| Yes | |
| No | |
| Number of modules | |
| Describe the key knowledge areas or themes assessed by the self-assessment program | |
| State the sources of information selected by the planning committee to develop the content of this activity | |
| Which learning methods were selected to help the CPD activity meet the stated learning objectives? Describe the rationale for the selected format to enable participants to review their current knowledge or skills in relation to current scientific evidence. | |
| Which learning methods will be used by participants to demonstrate or apply knowledge, skills, clinical judgement, or attitudes and record their answers? | |
| Assessment tool | |
| Role-play case scenarios | |
| Web-based assessment tool or link | |
| Answer sheet for the assessment tool | |
| If other learning method used, please describe | |
| Untitled | |
| Attach supporting documents of selected learning methods | |
| sap: Reviewer Checklist | |
| Feedback and reflection | |
| Which tools will be used to provide feedback to participants on their performance to enable the identification of any areas requiring improvement through the development of a future learning plan? | |
| Pre-test | |
| Post-test | |
| Feedback criteria tool | |
| Answer sheet | |
| Scoring tool | |
| Web based assessment tool | |
| If other feedback tool used, please describe | |
| Please add Sharepoint link to folder with the supporting documents of selected feedback tools | |
| Feedback must include if the answers are correct or incorrect with rational, and references to each question. Please describe how this will be done | |
| A sample must be provided of the selected feedback tool. Select which will be provided | |
| Sample document of answer with reference(s) | |
| Sample document of face-to-face instructor-group participants debrief with references | |
| Sample document of face-to-face instructor-individual participant debrief with references | |
| Sample document of the post-activity written evaluation of performance | |
| If other, please describe | |
| Please add Sharepoint link to folder with the sample of the selected feedback tool | |
| Describe the process used for administering a reflective tool | |
| Please add Sharepoint link to folder with the reflective tool | |
| far: Reviewer Checklist | |
| Simulation- based Activity | |
| Does this course have online modules | |
| Yes | |
| No | |
| Number of modules | |
| Describe the key knowledge areas or themes assessed by the simulation activity | |
| State the sources of information selected by the planning committee to develop the content of this activity | |
| Is this Online Simulation or Live Simulation? | |
| Online Simulation | |
| Live Simulation | |
| Describe how learners will provide responses to online simulation or synchronous or asynchronous oral responses | |
| Please add Sharepoint link to folder with the assessment tool | |
| Describe how learners will receive feedback after the completion of an online simulation | |
| Please add Sharepoint link to folder with the feedback tool | |
| Describe which simulation methods were selected to enable participants to demonstrate their abilities, skills, clinical judgement, or attitudes | |
| Describe how learners will participate in the simulation? | |
| Describe what process will be used to evaluate learners during the simulation | |
| Please add Sharepoint link to folder with the evaluation sheet | |
| Select the tools being used to provide feedback to participants on their performance to enable the identification of any areas requiring improvement through the development of a future learning plan | |
| Pre-test | |
| Post-test | |
| Feedback criteria tool | |
| Answer sheet | |
| Scoring tool | |
| Web based assessment tool | |
| Other | |
| If other feedback tool used, please describe | |
| Please add Sharepoint link to folder with the selected feedback tools | |
| Feedback must include if the answers are correct or incorrect with rational, and references to each question. Please describe how this will be done | |
| A sample must be provided of the selected feedback tool. Select which will be provided | |
| Sample document of answer with reference(s) | |
| Sample document of face-to-face instructor-group participants debrief with references | |
| Sample document of face-to-face instructor-individual participant debrief with references | |
| Sample document of the post-activity written evaluation of performance | |
| Other | |
| If other, please describe | |
| Please add Sharepoint link to folder with the selected feedback tool | |
| Describe the process used for administering a reflective tool | |
| Please add Sharepoint link to folder with the reflective tool | |
| sim: Reviewer Checklist | |
| Sponsorship | |
| Sponsorship | |
| Has the CPD activity been sponsored by one or more sponsors? | |
| Yes | |
| No | |
| If there is sponsorship, the conditions and purposes by which sponsorship is provided must be documented in a written agreement that is signed by the CPD provider organization and the sponsor. Please add Sharepoint link to the folder with the sponsorship agreement here | |
| Please explain if you don’t have agreements, or which agreements you will be submitting after this application | |
| Please add Sharepoint link to folder with the sponsorship prospectus or invitation | |
| If sponsorship has been received, are all details included in the CME budget form? | |
| Yes | |
| No | |
| If sponsorship has been received, has the SPC received advice from a sponsor as a condition of receiving financial and in-kind support? | |
| Yes | |
| No | |
| Please explain | |
| When acknowledging sponsorship, please use the standard acknowledgement statement, “This program has received an educational grant or in-kind support from (names of funding organizations)”. Do not include the sponsor’s logos in the slide deck, brochures, agenda and posters. Beyond the standard acknowledgement statement of financial and in-kind support, the linking or alignment of a sponsor’s name (or other branding strategies) to a specific educational session or section of an educational program within an accredited group learning activity is prohibited. Please check each box if you agree to the statement. Please check each box if you agree to the requirement | |
| I agree to use the standard acknowledgement statement when recognizing sponsorship. “This program has received an educational grant or in-kind support from (names of funding organizations)” | |
| I agree to not include the sponsor’s logos in the slide deck, brochures, agenda and posters. | |
| I agree to not link or align sponsor’s names (or other branding strategies) to a specific educational session or section of an educational program within an accredited group learning activity. | |
| How is sponsorship being disclosed to the participants? | |
| Welcome Session | |
| Brochure | |
| Separate sponsorship handout | |
| Slide Deck | |
| Agenda | |
| Signage | |
| Website | |
| Poster | |
| Are there any commercial or not-for-profit sponsors or any organizations hired by a sponsor on the SPC? | |
| Yes | |
| No | |
| Please explain | |
| Does the SPC ensure that their interactions with sponsors meet professional and legal standards including the protection of privacy, confidentiality, copyright and contractual law regulations? | |
| Yes | |
| No | |
| spon: Reviewer Checklist | |
| Exhibitors and advertisements | |
| Are there any commercial or not-for-profit exhibitors or advertisements? | |
| Yes | |
| No | |
| Does the SPC comply with the requirement that product-specific advertising, promotional materials logos, or branding strategies cannot be included on, appear within, or be adjacent to: | |
| Any educational materials, slides, abstracts and handouts used as part of an accredited CPD activity | |
| Activity agendas, programs or calendars of events (preliminary and final) | |
| Any webpages or electronic media containing educational material | |
| Does the SPC comply with the requirement that product-specific advertising, promotional materials or branding strategies cannot be included on/appear within locations where accredited CPD sessions are occurring (e.g. lecture halls, small group discussion rooms) immediately before, during or immediately after an accredited CPD activity | |
| Yes | |
| No | |
| Does the SPC comply with the requirement that commercial exhibits or advertisements must be arranged in a location that is clearly and completely separated from the accredited CPD activity | |
| Yes | |
| No | |
| Provide a map of the where the lecture hall/facility been provided showing location of the CPD sessions and the exhibitors | |
| What arrangements have you made to ensure separation of exhibits and educational activity? | |
| exa: Reviewer Checklist | |
| Integrity | |
| The SPC may consider data or advice from all sources but must ensure that decision- making related to the following CPD program elements is under its exclusive control. The following CPD elements are under exclusive control of the SPC. Select all that apply | |
| The identification of the educational needs of the intended target audience | |
| Development of learning objectives; providing information to speaker who will develop the learning objectives | |
| Selection of educational methods | |
| Selection of speakers, moderators, facilitators, and authors | |
| Development and delivery of content | |
| Evaluation of outcomes | |
| If any areas were not under exclusive control of the SPC, please explain | |
| The SPC must ensure content for this activity is scientifically valid, objective, and balanced across relevant therapeutic options. Select the options that the Scientific Planning Committee reviewed presentation materials for | |
| Addressing any potential conflicts of interest | |
| Incorporation of evidence | |
| Appropriateness of selected educational delivery methods | |
| Copyright adherence | |
| If any areas of review were not covered by the SPC, please explain | |
| In terms of Content Development, the SPC must have a process in place to deal with instances where CPD activities are not in compliance with the National Standard, Element 2. Please describe this process | |
| In terms of Conflict of Interest, a process must be in place for gathering, managing, and disclosing Conflicts of Interest (COIs). Please describe this process | |
| Describe how speakers, author’s, moderators, and facilitator’s COIs being collected and disclosed to both physician organization and learners attending the CPD activity | |
| Any individual who fails to disclose their relationships as described in the National Standard Element 3.1 & 3.3 cannot participate as a member of the SPC, speaker, moderator, facilitator, or author of an accredited CPD activity. Do you comply with this requirement? | |
| The Declaration of Conflict of Interest (COI) document provided to SPC and Speakers must ask to disclose the following below. Select all that are included in the COI | |
| Any direct financial payments including receipt of honoraria | |
| Membership on advisory boards or speakers’ bureaus | |
| Funded grants or clinical trials | |
| Patents on a drug, product or device | |
| All other investments or relationships that could be seen by a reasonable, well informed participant as having the potential to influence the content of the educational activity | |
| What are the Scientific Planning Committee’s methods to manage potential or real conflicts of interest? This is when a conflict of interest occurs during the live activity. Please describe the plan | |
| Do any participants receive payment for their travel, lodging or other out of pocket expenses? | |
| Yes | |
| No | |
| Please explain | |
| Has any travel, lodging or other out of pocket expenses of spouses, partners or other family members of: the SPC, speakers, moderators, facilitators, authors or participants been paid for or subsidized by the CPD provider organization, sponsor or any organization hired by a sponsor? | |
| Yes | |
| No | |
| Please explain | |
| Has the Scientific Planning Committee retained overall accountability for payment of travel, lodging, out-of-pocket expenses, and honoraria made to members of the SPC, speakers, moderators, facilitators, and authors? | |
| Yes | |
| No | |
| Is the responsibility for these payments delegated to a third party? | |
| Yes | |
| No | |
| Please describe how the CPD provider organization or SPC retains overall accountability for these payments | |
| Does the Scientific Planning Committee agree to ensure that product specific advertising, promotional materials, logos or other branding strategies have not been included on, appear within, or be adjacent to any educational materials, activity agendas, programs, or calendars of events, and/or any webpages or electronic media containing educational material | |
| Yes | |
| No | |
| Were incentives or “swag” provided to participants associated with an accredited CPD activity? | |
| Yes | |
| No | |
| Describe the incentives or “swag” and how they were reviewed and approved by the physician organization? | |
| Which strategies were used by the scientific planning committee to prevent the scheduling of unaccredited CPD activities occurring at time and locations where accredited activities were scheduled? | |
| Are there any unaccredited CPD activities? | |
| Yes | |
| No | |
| Select the options below to state that you agree | |
| I agree that unaccredited CPD activities will take place at times and locations that do not interfere with or compete with accredited CPD activities | |
| I agree that unaccredited CPD activities will not be listed or included in agendas, programs, or calendars of events | |
| Are there any non CPD activities? Select the options below to state that you agree | |
| Yes, and I agree to mark them as “unaccredited” within agendas, programs, or calendars of events preliminary and final | |
| No | |
| Please describe | |
| int: Reviewer Checklist | |
| Web-based CPD Activities | |
| Web-based CPD Activities | |
| Is this a Is this a web-based / online delivery method? | |
| Yes | |
| No | |
| Learning activities delivered via the web must provide an opportunity for interaction between participants and faculty/facilitator(s). Describe how interactivity between participants and faculty/facilitators will be incorporated | |
| Group learning activities delivered via the web must enable participants to observe the interaction of other participants with the faculty/facilitator(s). Describe how observation of other participants interaction with faculty/facilitators will be incorporated | |
| Participants must log on to the interactive component to claim credit under Section 1. Describe how participants will log on to the interactive component | |
| Certificates of participation should only be given to participants if they have logged on to the interactive component for the course. Describe how attendance is monitored and how the certificates to participants will be provided after they have logged on | |
| web: Reviewer Checklist | |
| CPD Accreditation Agreements | |
| CPD Accreditation Agreements | |
| If you have arranged for this CPD activity to be eligible for credit within any of these systems, please check all that apply | |
| American Medical Association (AMA) PRA Category 1 Credit™ | |
| European Union of Medical Specialists (UEMS) | |
| Qatar Council for Healthcare Practitioners (QCHP) | |
| European Board for Accreditation in Cardiology (EBAC) | |
| If this activity was accredited for another system, which one | |
| caa: Reviewer Checklist | |
| Needs Assessment | |
| Needs Assessment | |
| File | Functional-Inquiry.doc?rlkey=9wi88bnp4071n9exzc21zfcvx&dl=0 |
| nas: Reviewer Checklist | |
| Conflict of Interest Disclosure Forms | |
| Conflict of Interest Disclosure Forms | |
| File | |
| coi: Reviewer Checklist | |
| Sponsor Letter and Written Agreement | |
| slwa: Reviewer Checklist | |
| Program and Learning Objectives | |
| Program and Learning Objectives | |
| File | |
| plo: Reviewer Checklist | |
| Program Evaluation | |
| Program Evaluation | |
| File | |
| pval: Reviewer Checklist | |
| Brochure/ Promotional Materials | |
| Brochure/ Promotional Materials | |
| File | |
| pro: Reviewer Checklist | |
| Certificate of Attendance | |
| Certificate of Attendance | |
| File | |
| cert: Reviewer Checklist | |
| Budget | |
| Budget | |
| bud: Reviewer Checklist | |
| File | |
| Declaration | |
| Declaration | |
| By clicking “I agree” you are agreeing to the declaration stated below | |
| I agree | |
| Name of Chair | |
| Signature of Chair | |
| Date of signature | |
| dec: Reviewer Checklist | |
| Signature | |
| Reviewer | |
| Reviewer | |
| Overall Assessment | The activity meets all the education standards and quality criteria |
| Reviewer comments | |
| Name of reviewer | |
| Signature of reviewer | |
| Date of review |