AACT Activity Request Form

For AACT Activities requesting CME, please complete the CME Activity Form below. If your webinar/virtual event will not be requesting CME, please complete the Non-CME Activity Form.

CME Activity Form

AACT Activity Form - with CME

Proposed Activity Title(Required)

Activity Type(Required)

Activity Date(Required)

Month

Day

Year

1) Brief description and overall purpose of this educational session that will entice your audience to attend and set realistic expectations of the content:(Required)

Maximum of 100 words.

Target Audience(Required)

Pharmacist

Physician

Nurse

Other

If you selected 'other" please describe:(Required)

What professional practice gap is the activity addressing?(Required)

Identify what problem we are addressing – the gap is the difference between a perfect world and the actual world we live in. Using statistics are often helpful in explaining what the gap is. Ex: 1 in 8 will develop breast cancer, early detection can help minimize that statistic, so the goal is to close the knowledge gap between 0 in 8 vs the real world 1 in 8. (Maximum 100 words)

What educational need is the cause of this practice gap?(Required)

This is what the presenter is going to do to help close the gap identified in #1(practice gap is a problem or an issue that we are looking to help solve). What does the presenter need to teach the learner to help close/solve the gap/problem? (Maximum 50 words)

From your perspective, how did you design this activity to improve skills/strategy of the healthcare team?(Required)

From the planner perspective, why do you believe that the learners, after attending this event, will have sufficiently improved skills so that the identified gap and need are overcome? What are the take-aways from attending this event (i.e. learner objectives)? (Maximum 50 words)

What is the target audience of this activity, and how does the planning committee reflect that audience?(Required)

Simply identify those professions that this activity is intended to reach and how those professions are represented on the planning committee. (Maximum 50 words)

How are you ensuring this activity is generated around valid content(Required)

Here, you outline how the activity meets ACCME Standard 1, in that you are ensuring the education is fair and balanced and that any clinical content presented supports safe, effective patient care. For more information on Standard 1, please visit: https://www.accme.org/accreditation-rules/standards-for-integrity-independence-accredited-ce/standard-1-ensure-content-valid (Maximum 50 words)

Is there anything in this activity that any planner thinks may not be valid content? If yes, please explain.(Required)

It’s not unheard of that those serving on a planning committee have different opinions or even disagreements over the validity of selected content. Please use this area to outline any such occurrence in the planning of this activity and, if so, how the committee worked to resolve the issue. If no such issue arose here, please enter N/A. (Maximum 50 words)

Needs Assessment Documentation(Required)

Expert Opinion

Government/Regulatory Requirement

Peer-Reviewed Literature

Board/Re-Certification Requirement

National Guidelines

Needs Assessment Survey

Other

If "other" please describe.(Required)

Name of expert, guideline, research, etc. (Maximum 60 words) or what the expert, guideline, research or other says that supports the need (Maximum 25 words)

Activity Type(Required)

Learning Objectives

ACPE and ACCME require active learning and learning assessment for each session objective. Most sessions will be required to use some form of an audience response system to meet this standard. Staff will work with the presenter/organizer to incorporate active learning into the presentations. Only proposals with these elements will be considered. Further, there should be 3 learning objectives for every hour of CE activity (or one for each 15-minute sessions if more or less than one hour). Each objective must have one multiple choice (or true and false) learning assessment question to be presented during the activity. View tips for writing learning objectives here: https://degnonassociatesinc.sharepoint.com/:w:/s/degnonallmembers/Ef5rlrVfa3hNvhcMUR--jLEBfrnK-P7PSR6R6bsF5Dz9NQ?e=lPJGgt

Learning Objective 1(Required)

A description of a specific patient, develop a medication regimen that reflects application of the best evidence and current guidelines. Max 14 words.

Active Learning Strategy 1(Required)

Such as an interactive case study describing a patient with a specific condition and how to develop a medication regime based on symptoms and lab test results. Max 25 words.

Learning Assessment 1(Required)

Solution to the case study with evidence-based references and current guidelines being applied. Max 25 words.

Learning Objective 2(Required)

A description of a specific patient, develop a medication regimen that reflects application of the best evidence and current guidelines. Max 14 words.

Active Learning Strategy 2(Required)

Such as an interactive case study describing a patient with a specific condition and how to develop a medication regime based on symptoms and lab test results. Max 25 words.

Learning Assessment 2(Required)

Solution to the case study with evidence-based references and current guidelines being applied. Max 25 words.

Learning Objective 3(Required)

A description of a specific patient, develop a medication regimen that reflects application of the best evidence and current guidelines. Max 14 words.

Active Learning Strategy 3(Required)

Such as an interactive case study describing a patient with a specific condition and how to develop a medication regime based on symptoms and lab test results. Max 25 words.

Learning Assessment 3(Required)

Solution to the case study with evidence-based references and current guidelines being applied. Max 25 words.

Assessment of Learning and Assessment Feedback

For Knowledge-Based Activities must include assessment questions structured to determine the recall of facts based on learning objectives. Techniques can be informal such as audience response systems, color cards, or raising of hands. Feedback may include the correct response to questions. For Application-Based Activities include case studies structured to address the application of the principles learned based on the learning objectives. Feedback may include correct evaluation of case studies. For both types of activities, when response are incorrect, communicate a question was answered incorrectly and provide the rationale for the correct response.

Knowledge-Based Activity(Required)

If your activity is a knowledge-based activity, please match your active learning strategies to this activity type. Select all that are applicable. If your activity is an application-based activity, select NA. Activities can be both knowledge-based and application-based. If this is your activity, answer this question and the question below.

Lecture with questions

Games and quizzes to practice recall

Demonstration

Example with practice

Interactive case study

Interactive scenario

Role play

Simulation

Application exercises

Practice exercises

Application-Based Activity(Required)

If your activity is an application-based activity, please match your active learning strategies to this activity type. Select all that are applicable. If your activity is a knowledge-based activity, select NA.

Lecture with questions

Games and quizzes to practice recall

Demonstration

Example with practice

Interactive case study

Interactive scenario

Role play

Simulation

Application exercises

Practice exercises

Length of Entire Session(Required)

Continuing education credit is given in 15-minute increments only. Shorter sessions are preferred by meeting attendees. ACPE no longer allows partial attendance; in order to claim CE an attendee must stay for the entire duration; thus, shorter sessions are desirable. If you selected Application-Based, your session must be at least 30 minutes. Please select only one choice.

1 hour - 3 presenters max

75 minutes - 4 presenters max

90 minutes - 4 presenters max

2 hours - 4 presenters max

Educational Level of Content(Required)

General interest: Level designation not applicable to this session.

Intermediate: Basic knowledge of the specific content area is suggested but, extensive experience is not necessary.

Advanced: General working knowledge of the specific content area suggested, information will be provided to expand current expertise.

Session Outline(Required)

Prepare a proposed outline of your educational session, include a description and proposed speaker for each topic and include the time allocated to each topic.

Proposed Presenter(s)

Provide information on each proposed presenter. Presenters should reflect practice trends from around the country (geographically diverse) and provide attendees with various perspectives in the same subject. Proposals with minimal or no geographically diverse faculty are generally not accepted for presentation. Only the fields for the first presenter are required, however it is expected if you have more than one presenter, you will fill out the corresponding fields. All presenters will be emailed a conflict of interest (COI) disclosure form that must be filled out 30 days prior to the activity. If the COI form is not filled out prior to the activity, the individual will be unable to present. *It is understood that the speakers you list are those you will pursue upon acceptance of this proposal. Do not confirm your speakers at this time.

How many presenters will your proposed activity have?(Required)

One Presenter

Two Presenters

Three Presenters

Four Presenters

Presenter 1 Full Name(Required)

Include degrees, credentials and/or designations

Presenter 1 Email Address(Required)

Presenter 1 Title/Position(Required)

Presenter 1 Institution/Organization

Presenter 1 Address(Required)

City, State

Presenter 1 Expertise/qualifications on the Proposed Topic.(Required)

Maximum 250 words

Presenter 1 Biosketch(Required)

Presenter 2 Full Name(Required)

Include degrees, credentials and/or designations

Presenter 2 Email Address(Required)

Presenter 2 Title/Position(Required)

Presenter 2 Institution/Organization

Presenter 2 Address(Required)

City, State

Presenter 2 Expertise/qualifications on the Proposed Topic.(Required)

Maximum 250 words

Presenter 2 Biosketch(Required)

Presenter 3 Full Name(Required)

Include degrees, credentials and/or designations

Presenter 3 Email Address(Required)

Presenter 3 Title/Position(Required)

Presenter 3 Institution/Organization

Presenter 3 Address(Required)

City, State

Presenter 3 Expertise/qualifications on the Proposed Topic.(Required)

Maximum 250 words

Presenter 3 Biosketch(Required)

Presenter 4 Full Name(Required)

Include degrees, credentials and/or designations

Presenter 4 Email Address(Required)

City, State

Presenter 4 Title/Position(Required)

City, State

Presenter 4 Institution/Organization

City, State

Presenter 4 Address(Required)

City, State

Presenter 4 Expertise/qualifications on the Proposed Topic.(Required)

Maximum 250 words

Presenter 4 Biosketch(Required)

Proposed Moderator(s)

How many moderators will your proposed activity have?(Required)

One Moderator

Two Moderators

Three Moderators

Moderator 1 Full Name(Required)

Include degrees, credentials and/or designations

Moderator 1 Email Address(Required)

Moderator 1 Title/Position(Required)

Moderator 1 Institution/Organization

Moderator 1 Address(Required)

City, State

Moderator 2 Full Name(Required)

Include degrees, credentials and/or designations

Moderator 2 Email Address(Required)

Moderator 2 Title/Position(Required)

Moderator 2 Institution/Organization

Moderator 2 Address(Required)

City, State

Moderator 3 Full Name(Required)

Include degrees, credentials and/or designations

Moderator 3 Email Address(Required)

Moderator 3 Title/Position(Required)

Moderator 3 Institution/Organization

Moderator 3 Address(Required)

City State / Province / Region

Non-CME Activity Form

AACT Activity Form for Webinars - Non-CME

Proposed Activity Title(Required)

Activity Type(Required)

Activity Date(Required)

Month

Day

Year

1) Brief description and overall purpose of this educational session that will entice your audience to attend and set realistic expectations of the content:(Required)

Maximum of 100 words.

Target Audience(Required)

Pharmacist

Physician

Nurse

Other

If you selected 'other" please describe:(Required)

What professional practice gap is the activity addressing?(Required)

What educational need is the cause of this practice gap?(Required)

From your perspective, how did you design this activity to improve skills/strategy of the healthcare team?(Required)

Needs Assessment Documentation(Required)

Expert Opinion

Government/Regulatory Requirement

Peer-Reviewed Literature

Board/Re-Certification Requirement

National Guidelines

Needs Assessment Survey

Other

If "other" please describe.(Required)

Name of expert, guideline, research, etc. (Maximum 60 words) or what the expert, guideline, research or other says that supports the need (Maximum 25 words)

Activity Type(Required)

Learning Objectives

Learning Objective 1(Required)

A description of a specific patient, develop a medication regimen that reflects application of the best evidence and current guidelines. Max 14 words.

Learning Objective 2(Required)

A description of a specific patient, develop a medication regimen that reflects application of the best evidence and current guidelines. Max 14 words.

Learning Objective 3(Required)

A description of a specific patient, develop a medication regimen that reflects application of the best evidence and current guidelines. Max 14 words.

Assessment of Learning and Assessment Feedback

Knowledge-Based Activity(Required)

Lecture with questions

Games and quizzes to practice recall

Demonstration

Example with practice

Interactive case study

Interactive scenario

Role play

Simulation

Application exercises

Practice exercises

Application-Based Activity(Required)

Lecture with questions

Games and quizzes to practice recall

Demonstration

Example with practice

Interactive case study

Interactive scenario

Role play

Simulation

Application exercises

Practice exercises

Length of Entire Session(Required)

1 hour - 3 presenters max

75 minutes - 4 presenters max

90 minutes - 4 presenters max

2 hours - 4 presenters max

Educational Level of Content(Required)

General interest: Level designation not applicable to this session.

Intermediate: Basic knowledge of the specific content area is suggested but, extensive experience is not necessary.

Advanced: General working knowledge of the specific content area suggested, information will be provided to expand current expertise.

Session Outline(Required)

Prepare a proposed outline of your educational session, include a description and proposed speaker for each topic and include the time allocated to each topic.

Proposed Presenter(s)

How many presenters will your proposed activity have?(Required)

One Presenter

Two Presenters

Three Presenters

Four Presenters

Presenter 1 Full Name(Required)

Include degrees, credentials and/or designations

Presenter 1 Email Address(Required)

Presenter 1 Title/Position(Required)

Presenter 1 Institution/Organization

Presenter 1 Biosketch(Required)

Presenter 2 Full Name(Required)

Include degrees, credentials and/or designations

Presenter 2 Email Address(Required)

Presenter 2 Title/Position(Required)

Presenter 2 Institution/Organization

Presenter 2 Biosketch(Required)

Presenter 3 Full Name(Required)

Include degrees, credentials and/or designations

Presenter 3 Email Address(Required)

Presenter 3 Title/Position(Required)

Presenter 3 Institution/Organization

Presenter 3 Biosketch(Required)

Presenter 4 Full Name(Required)

Include degrees, credentials and/or designations

Presenter 4 Email Address(Required)

City, State

Presenter 4 Title/Position(Required)

City, State

Presenter 4 Institution/Organization

City, State

Presenter 4 Biosketch(Required)

Proposed Moderator(s)

How many moderators will your proposed activity have?(Required)

One Moderator

Two Moderators

Three Moderators

Moderator 1 Full Name(Required)

Include degrees, credentials and/or designations

Moderator 1 Email Address(Required)

Moderator 1 Title/Position(Required)

Moderator 1 Institution/Organization

Moderator 2 Full Name(Required)

Include degrees, credentials and/or designations

Moderator 2 Email Address(Required)

Moderator 2 Title/Position(Required)

Moderator 2 Institution/Organization

Moderator 3 Full Name(Required)

Include degrees, credentials and/or designations

Moderator 3 Email Address(Required)

Moderator 3 Title/Position(Required)

Moderator 3 Institution/Organization

AACT Activity Form - with CME

Proposed Activity Title(Required)

Activity Type(Required)

Activity Date(Required)

Month

Day

Year

1) Brief description and overall purpose of this educational session that will entice your audience to attend and set realistic expectations of the content:(Required)

Maximum of 100 words.

Target Audience(Required)

Pharmacist

Physician

Nurse

Other

If you selected 'other" please describe:(Required)

What professional practice gap is the activity addressing?(Required)

What educational need is the cause of this practice gap?(Required)

From your perspective, how did you design this activity to improve skills/strategy of the healthcare team?(Required)

What is the target audience of this activity, and how does the planning committee reflect that audience?(Required)

Simply identify those professions that this activity is intended to reach and how those professions are represented on the planning committee. (Maximum 50 words)

How are you ensuring this activity is generated around valid content(Required)

Is there anything in this activity that any planner thinks may not be valid content? If yes, please explain.(Required)

Needs Assessment Documentation(Required)

Expert Opinion

Government/Regulatory Requirement

Peer-Reviewed Literature

Board/Re-Certification Requirement

National Guidelines

Needs Assessment Survey

Other

If "other" please describe.(Required)

Name of expert, guideline, research, etc. (Maximum 60 words) or what the expert, guideline, research or other says that supports the need (Maximum 25 words)

Activity Type(Required)

Learning Objectives

Learning Objective 1(Required)

A description of a specific patient, develop a medication regimen that reflects application of the best evidence and current guidelines. Max 14 words.

Active Learning Strategy 1(Required)

Such as an interactive case study describing a patient with a specific condition and how to develop a medication regime based on symptoms and lab test results. Max 25 words.

Learning Assessment 1(Required)

Solution to the case study with evidence-based references and current guidelines being applied. Max 25 words.

Learning Objective 2(Required)

A description of a specific patient, develop a medication regimen that reflects application of the best evidence and current guidelines. Max 14 words.

Active Learning Strategy 2(Required)

Such as an interactive case study describing a patient with a specific condition and how to develop a medication regime based on symptoms and lab test results. Max 25 words.

Learning Assessment 2(Required)

Solution to the case study with evidence-based references and current guidelines being applied. Max 25 words.

Learning Objective 3(Required)

A description of a specific patient, develop a medication regimen that reflects application of the best evidence and current guidelines. Max 14 words.

Active Learning Strategy 3(Required)

Such as an interactive case study describing a patient with a specific condition and how to develop a medication regime based on symptoms and lab test results. Max 25 words.

Learning Assessment 3(Required)

Solution to the case study with evidence-based references and current guidelines being applied. Max 25 words.

Assessment of Learning and Assessment Feedback

Knowledge-Based Activity(Required)

Lecture with questions

Games and quizzes to practice recall

Demonstration

Example with practice

Interactive case study

Interactive scenario

Role play

Simulation

Application exercises

Practice exercises

Application-Based Activity(Required)

Lecture with questions

Games and quizzes to practice recall

Demonstration

Example with practice

Interactive case study

Interactive scenario

Role play

Simulation

Application exercises

Practice exercises

Length of Entire Session(Required)

1 hour - 3 presenters max

75 minutes - 4 presenters max

90 minutes - 4 presenters max

2 hours - 4 presenters max

Educational Level of Content(Required)

General interest: Level designation not applicable to this session.

Intermediate: Basic knowledge of the specific content area is suggested but, extensive experience is not necessary.

Advanced: General working knowledge of the specific content area suggested, information will be provided to expand current expertise.

Session Outline(Required)

Prepare a proposed outline of your educational session, include a description and proposed speaker for each topic and include the time allocated to each topic.

Proposed Presenter(s)

How many presenters will your proposed activity have?(Required)

One Presenter

Two Presenters

Three Presenters

Four Presenters

Presenter 1 Full Name(Required)

Include degrees, credentials and/or designations

Presenter 1 Email Address(Required)

Presenter 1 Title/Position(Required)

Presenter 1 Institution/Organization

Presenter 1 Address(Required)

City, State

Presenter 1 Expertise/qualifications on the Proposed Topic.(Required)

Maximum 250 words

Presenter 1 Biosketch(Required)

Presenter 2 Full Name(Required)

Include degrees, credentials and/or designations

Presenter 2 Email Address(Required)

Presenter 2 Title/Position(Required)

Presenter 2 Institution/Organization

Presenter 2 Address(Required)

City, State

Presenter 2 Expertise/qualifications on the Proposed Topic.(Required)

Maximum 250 words

Presenter 2 Biosketch(Required)

Presenter 3 Full Name(Required)

Include degrees, credentials and/or designations

Presenter 3 Email Address(Required)

Presenter 3 Title/Position(Required)

Presenter 3 Institution/Organization

Presenter 3 Address(Required)

City, State

Presenter 3 Expertise/qualifications on the Proposed Topic.(Required)

Maximum 250 words

Presenter 3 Biosketch(Required)

Presenter 4 Full Name(Required)

Include degrees, credentials and/or designations

Presenter 4 Email Address(Required)

City, State

Presenter 4 Title/Position(Required)

City, State

Presenter 4 Institution/Organization

City, State

Presenter 4 Address(Required)

City, State

Presenter 4 Expertise/qualifications on the Proposed Topic.(Required)

Maximum 250 words

Presenter 4 Biosketch(Required)

Proposed Moderator(s)

How many moderators will your proposed activity have?(Required)

One Moderator

Two Moderators

Three Moderators

Moderator 1 Full Name(Required)

Include degrees, credentials and/or designations

Moderator 1 Email Address(Required)

Moderator 1 Title/Position(Required)

Moderator 1 Institution/Organization

Moderator 1 Address(Required)

City, State

Moderator 2 Full Name(Required)

Include degrees, credentials and/or designations

Moderator 2 Email Address(Required)

Moderator 2 Title/Position(Required)

Moderator 2 Institution/Organization

Moderator 2 Address(Required)

City, State

Moderator 3 Full Name(Required)

Include degrees, credentials and/or designations

Moderator 3 Email Address(Required)

Moderator 3 Title/Position(Required)

Moderator 3 Institution/Organization

Moderator 3 Address(Required)

City State / Province / Region

For AACT Activities requesting CME, please complete the CME Activity Form below. If your webinar/virtual event will not be requesting CME, please complete the Non-CME Activity Form.

AACT Activity Form - with CME

Learning Objectives

Assessment of Learning and Assessment Feedback

Proposed Presenter(s)

Proposed Moderator(s)

AACT Activity Form for Webinars - Non-CME

Learning Objectives

Assessment of Learning and Assessment Feedback

Proposed Presenter(s)

Proposed Moderator(s)

AACT Activity Form - with CME

Learning Objectives

Assessment of Learning and Assessment Feedback

Proposed Presenter(s)

Proposed Moderator(s)

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