Continuing Education Application

The following application can be used for all educational programs seeking accreditation. Please complete the following forms, and submit to continuingeducation@childrens.harvard.edu.

Nursing credit only applications should be sent to Greg Durkin at Gregory.Durkin@childrens.harvard.edu.

ALL FIELDS ARE REQUIRED when submitting this application. If fields or documentation are missing, the application will be sent back to the submitter.

Documentation includes: disclosure forms or an electronic disclosure list, references/supporting documents, and signature on budget form; these must be submitted with the application for it to be considered complete.

The eight week review period begins once a fully completed application is submitted.

If you are seeking marketing support from Boston Children’s for your course please submit application, 4 months in advance for local; 6 months in advance for regional courses; 9-12 months in advance for national/international.

Disclosure and Content Attestation Forms from planners/presenters need to be received at least 4 weeks in advance of the educational activity.

All applications that are approved will be subject to an accreditation fee. Please review the accreditation fee policy here.

Some of the questions you should be prepared to answer are in the application:

Practice gaps - What is the problem/fact that you want to address?

Documentation for each gap - How do you know that the problem/fact exists?

Current practice vs. ideal practice- What is currently happening in practice that you are looking to change or improve?

Objectives – What is your goal for attendees after coming to your course?

Measurement process – How will you measure your effectiveness in making a change? What are barriers that could prevent change?

Resources:

Tips for Writing Learning Objectives

Tuition Guidelines

Blank Disclosure Form

Honorarium Policy

Conflict of Interest Policy

Industry Gift Solicitation Policy

Accreditation Fee Policy

Marketing Guidelines

Educational Activity Description
Activity Information
Title: Click here to enter text.
Department/Program: Click here to enter text.
Location: Click here to enter text.
Start Date: Click here to enter a date.	Start Time: Click here to enter text.
End Date: Click here to enter a date.	End Time: Click here to enter text.
Number of hours requested (program agenda required for sessions > 2 hours):	Click here to enter text.
Number of Risk Management Hours Requested: If you are seeking credits associated with the MA Board of Registration in Medicine (BORM) Opioid/Pain Management or End-of-Life Care training requirements, please identify which sessions you believe should receive such credit by highlighting them in yellow. The MA BORM requirements for receipt of such credit are as follows: 1. Opioid education and pain management training shall include, but not be limited to: training in how to identify patients at high risk for substance abuse and training in how to counsel patients on the side effects, addictive nature and proper storage and disposal of prescription medicines. 2. End-of-life care training shall include: Studying end-of-life care issues. Note: If you are seeking risk management credits, please highlight topics and explain why they meet the risk management criteria on your agenda Please visit http://web2.tch.harvard.edu/cme/ for more information on Risk Management	Click here to enter text.
Program Number:	(review staff will add this)
Is this a new activity? Yes: ☐ No: ☐
If no, what was the previous activity number? Click here to enter text.
Type of Activity
Please Select the type of activity from the options: Choose an item.
If you selected RSS, select the recurrence options: Choose an item. A Regularly Scheduled Series (RSS) is defined as an activity that is planned to have 1) a series with multiple sessions that 2) occur on an ongoing basis (offered weekly, monthly, or quarterly) and 3) are primarily planned by and presented to the accredited organization’s professional staff. Some examples would be grand rounds, case conferences, morbidity & mortality, or tumor boards.
If you selected “other” for either or both of the above, please describe here: Click here to enter text.
Accreditation Type Requested
☐	Physician Credits; Accreditation Council for Continuing Medical Education; AMA PRA Category 1
☐	Nursing Credits; American Nurses Credentialing Center, ANCC
☐	Dentistry Credits
☐	Physician Assistant Credits
☐	Pharmacy Credits ; Accreditation Council for Pharmacy Education, ACPE
☐	Optometry Credits
☐	Athletic Trainer Credits
☐	Other accreditation types (if applicable, and additional fees may apply): Click here to enter text.
☐	For CME credits, are you seeking risk management credits?
☐	For CME credits, are you seeking Maintenance of Certification Credits Part II (MOC II) If yes, what evaluation type will you be using? See this page 7 of this document for more details: Click here to enter text.
Planning Committee (JAC8)
Planning Committee: All members of the planning committee must complete a disclosure form prior to the start of the course/program. In addition, absence or presence of disclosure must be presented to learners through a sign or poster at registration site, printed in syllabus, or in presentation slides. There must be a planning representative from each discipline that credit is requested for. * A course director is described as the leading member(s) of the planning committee
Primary Boston Children’s Course Director (add more rows as needed)
Name, Degree (s) and Title
Organization, Department and Division	Click here to enter text.
Mailing Address	Click here to enter text.
Phone	Click here to enter text.
Email	Click here to enter text.
Course Director #2
Name, Degree (s) and Title	Click here to enter text.
Organization, Department and Division	Click here to enter text.
Mailing Address	Click here to enter text.
Phone	Click here to enter text.
Email	Click here to enter text.
Course Director #3
Name, Degree (s) and Title	Click here to enter text.
Organization, Department and Division	Click here to enter text.
Mailing Address	Click here to enter text.
Phone	Click here to enter text.
Email	Click here to enter text.
Course Director #4
Name, Degree (s) and Title	Click here to enter text.
Organization, Department and Division	Click here to enter text.
Mailing Address	Click here to enter text.
Phone	Click here to enter text.
Email	Click here to enter text.
Course Administrator/ Contact Person (Logistics Lead)
Name, Degree (s) and Title	Click here to enter text.
Organization, Department and Division	Click here to enter text.
Mailing Address	Click here to enter text.
Phone	Click here to enter text.
Email	Click here to enter text.
Other Planning Committee Members: List each Presenter/Author/Faculty/Content Reviewer
Name, Degree(s) and Title	Organization, Department and Division:	Role:	Email:
Activity Pricing; leave blank if no fee
Describe the tuition pricing structure and number of fee waiver applicants accepted. If additional fee types are needed, please add additional lines with a description of the fee type and price.
Physician Fee	$
Physician Fee (Early Bird Rate)	$
Nurse Fee	$
Nurse Fee (Early Bird Rate)	$
Pharmacist Fee	$
Pharmacist Fee (Early Bird Rate)	$
Trainee/Student Fee	$
Trainee/Student Fee (Early Bird Rate)	$
Other Fee	$
Fee Waiver Fee:	$
Early Bird Registration Date Deadline:	Click here to enter a date.
Activity Overview (JAC4)
Briefly, provide a course description/overview as you would like it to appear in print or electronic media such as an online calendar of activities. Please include one or more sentences about the practice gaps and educational needs for the course. In addition, include a statement about the educational methodologies used in the course. (Note: You may prefer to complete this question once you have completed the remainder of the proposal.)
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Competitive Analysis:
What are other existing similar courses and/or specialty society meetings? Please list the meetings, their dates, and locations. The following information is only necessary if you are marketing your course through Boston Children’s IPCE.
Meeting Name	Date(s)	Location
Target Audience
Provider Type:
☐	Primary Care Physicians
☐	Specialty Physicians
☐	Pharmacists
☐	Pharmacy Technician
☐	Psychologists
☐	Physician Assistants
☐	Advanced Practice Nurses
☐	Registered Nurses
☐	Registered Nurses in Specialty Areas
☐	Licensed Practical Nurses
☐	Allied Health Professional
☐	Dentist
☐	Social Workers
☐	Optometrists
☐	Ophthalmologists
☐	Occupational Therapists
☐	Physical Therapists
☐	Other, specify:
Specialties of Learners:
Geographic Location of Target Audience:
☐	Internal
☐	Local (Greater Boston Area)
☐	Regional (New England)
☐	National
☐	International, specify countries if possible:
☐	Other:
Topic Designator: Complete only if requesting Pharmacy (ACPE) Credit
☐	Not Applicable, no pharmacy credit is being requested
☐	Disease State Management/Drug Therapy	☐	General Pharmacy
☐	AIDS Therapy	☐	Patient Safety
☐	Law Related to Pharmacy Practice	☐	Other:
Planning Process (JAC 6)
How were the speakers and topics identified? Click here to enter text.
What criteria were used in the selection of speakers?
☐	Subject Matter Expert
☐	Excellent teaching skills/effective communicator
☐	Experienced in Interprofessional Continuing Education
☐	Recommended by colleague
Were any employees of a pharmaceutical company and/or medical device manufacturer involved with the identification of speakers and/or topics?
☐	Yes
☐	No
Needs Assessment (JAC 4)
Current Practice: What are the problems in practice that this activity is designed to change?(Current references required; number of references commensurate with length of program)
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Ideal Practice: Please describe the ideal practice that is new/ modern. In other words, what is the “best practice” that you aren’t seeing currently in a consistent way?
Click here to enter text.
Practice Gap/Need: What information does the target audience need and how will your course bring it forward. In other words, what information that is missing in order for people to do their work right now? Professional practice gaps are measured in terms of: (1) Knowledge: being aware of what to do (2) Competence: being able to apply knowledge, skills, and judgment in practice‐ knowing how to do something, and (3) Performance: having the ability to implement the strategy or skill‐what one actually does.)
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This is a gap/need of:
☐	Knowledge/Competence
☐	Skills/Strategy
☐	Performance
☐	Patient Outcomes (if selecting patient outcomes, please attach supporting data)
Needs Assessment Data and Sources (select 2 at minimum) *Please indicate how the need for this activity was brought to your attention. Check all that apply and provide supportive documentation for all boxes listed as required.
What sources did you utilize to identify your professional practice gaps and educational needs for the healthcare team?
☐	Publications/scientific literature (Documentation required)
☐	Outcomes data that support team-based education. Potential sources of documentation: tabulated data results of healthcare team changes in longitudinal performance across performance and practice guidelines, national, local or regional (team performance) (Documentation required)
☐	Continuing review of changes in quality care as revealed by medical audit or other patient care reviews. Potential sources of documentation: audit reports, chart reviews.
☐	Issues identified by colleagues
☐	Problem and/or uncommon cases
☐	Ongoing census of diagnosis made by physicians on staff Potential sources of documentation: summary of notes, minutes of meetings.
☐	Advice from authorities of the field or relevant professional societies. Potential sources of documentation: list of expert names/professional societies AND summary of recommendation(s)
☐	Formal or informal requests or surveys of the target audience, faculty or staff. Potential sources of documentation: summary of requests or surveys. Note, must show information related to areas of education need/topics of interest (not logistical summaries- ex. Food, venue, etc.) (Documentation required)
☐	Discussion in departmental meetings Potential sources of documentation: summary of meeting minutes showing information discussed was related to areas of education need/topics of interest. (not logistical topics- ex. Food, venue, etc.)
☐	Data from peer reviewed journals, government sources, consensus reports. Potential sources of documentation: abstracts/full journal articles, government produced documents describing educational need and provider practice gaps (Documentation required)
☐	Review of board examinations and/or re-certification requirements. Potential sources of documentation: board review/update requirements
☐	New technology, methods of diagnosis/treatment Potential sources of documentation: description of new procedure, technology treatment, etc. (Documentation required)
☐	Legislative, regulatory or organizational changes affecting patient care. Potential sources of documentation: copy of the measure/change
☐	Joint Commission Patient Safety Goal/Competency Potential source of documentation: copy of the safety goal and/or competency
☐	Other, please specify:
Required Documentation: Insert all documentation (for example, journal article citations) in the space below:
10.Based on the practice gaps, educational needs, desired change, what topics will the activity cover?
Attach an agenda for your activity in the space provided below if your activity is longer than two hours. If this activity is approved, credit will be calculated based on information provided in this schedule. Within your agenda, please provide the following information: Day and date for each day of the course Beginning and ending times for each session Name, Credentials, Title and Institution/Employer for each faculty member Identify which faculty have been confirmed Information about breaks and meals (particularly if credit is being sought for meal time education) Describe/identify what will take place during sessions that are not easily understood by their titles or are not typical educational methodologies (e.g. “Meet the Professor”). Please add more lines as needed.
Date	Time Start	Time End	Speaker	Description/Topic
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Click here to enter a date.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.
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Please add more lines as needed.
11. Learning Objectives (JAC 5) The learning objectives outlined below should be able to complete the following statement: “Upon completion of this course participants will be able to:….”
Objective	Content Topics
See tips for writing learning objectives	Content outline for each objective
Learning Objective 1:	Click here to enter text.	Click here to enter text.
Learning Objective 2:	Click here to enter text.	Click here to enter text.
Learning Objective 3:	Click here to enter text.	Click here to enter text.
Add more rows as necessary
12. Educational Design/Methodology (JAC 7) Please indicate the educational method(s) that will be used:
☐	Didactic Lecture	☐	Simulations
☐	Panel Discussions	☐	Hands on skills training
☐	Roundtable discussions	☐	Audio recording
☐	Q & A Sessions	☐	Video/film recording
☐	Case presentations	☐	Other form, please specify:
Were any non-educational strategies used? Non-educational strategies are used to enhance change as an adjunct to activities/educational interventions, examples below: Patient reminders Patient satisfaction, questionnaires Incentives Peer to peer feedback Emailing Information on CME Topic to Program Participants After the Event Qualitative focus groups Quantitative surveys Pocket guidelines for physicians Chart reminders Pedometers or other give-away items to support CME activity Screening tools Information posted on website Stickers Changes in hospital policy Reminders in staff meetings Posters and signs Patient education materials
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13. Identified Barriers to Change (JAC 12, 13) What are the potential barriers (perceived or real) that may prevent learners from putting into practice what they have learned? (Select one at a minimum,)
☐	Lack of time to assess or counsel patients	☐	Lack of consensus on professional guidelines
☐	Lack of administrative support/resources	☐	Cost
☐	Beliefs and attitudes of healthcare professionals	☐	Uncertain roles/role expectations of healthcare professionals
☐	Insurance/reimbursement issues	Other, please specify: Click here to enter text.
☐	Patient Compliance Issues
Please describe how you will attempt to address these identified barriers in the educational activity:
Click here to enter text.
What factors outside of your control impact patient outcomes? (JAC 10) *ie. Other commitments, family restrictions, etc.
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14. Please identify how this activity will align with the educational mission of Boston Children’s Hospital (JAC2): Boston Children’s Hospital will be recognized regionally, nationally and internationally as a premier provider of up-to-date healthcare knowledge, technological advancements, and skills development to the healthcare team. We will promote excellence in continuing education to improve the quality of healthcare within and beyond the hospital setting. Boston Children's Hospital strives to provide valuable continuing education opportunities as well as effective resources. Boston Children’s Hospital Interprofessional Continuing Education program shall address the intellectual and practical needs of the healthcare team by offering structured activities designed to improve: patient health using evidence and case based activities, professional practice gaps of the healthcare team, care from clinicians by providing resources to support clinical, teaching, research and/or administrative changes as a result of activities, strategies to overcome clinician barriers that are impairing the ability to provide optimal patient care, and the understanding of interprofessional roles to improve teamwork among members of the healthcare team.
☐	Patient health using evidence and case based activities
☐	Professional practice gaps of the healthcare team
☐	Care from clinicians by providing resources to support clinical, teaching, research and/or administrative changes as a result of activities
☐	Strategies to overcome clinician barriers that are impairing the ability to provide optimal patient care
☐	Understanding of interprofessional roles to improve teamwork among members of the healthcare team
☐	Other, please specify:
Which of the following competencies has this activity been designed to enhance? (Source: Accreditation Council for Graduate Medical Education (ACGME), Institute of Medicine (IOM), Interprofessional Education Collaborative(IPEC), Center for the Advancement of Pharmacy Education (CAPE), Pharmacy Technician Certification Board (PTCB) Select one or more of the following (JAC8):
☐	Patient and Procedural Skills (ABMS/ACGME)
☐	Medical Knowledge (ABNS/ACGME)
☐	Practice Based Learning and Improvement (ABMS/ACGME)
☐	Interpersonal and Communication Skills (ABMS/ACGME)
☐	Professionalism (ABMS/ACGME, CAPE)
☐	Systems-based Practice (ABMS/ACGME)
☐	Provide patient-centered care (IOM)
☐	Work in interdisciplinary teams (IOM)
☐	Employ evidence-based practice (IOM)
☐	Apply quality improvement (IOM)
☐	Utilize informatics (IOM)
☐	Values/ethics for interprofessional practice (IPEC)
☐	Roles/responsibilities (IPEC)
☐	Interprofessional Communication (IPEC)
☐	Teams and Teamwork (IPEC)
☐	Communication (CAPE)
☐	Cultural sensitivity (CAPE)
☐	Educator (CAPE)
☐	Health and wellness (CAPE)
☐	Innovation and entrepreneurship (CAPE)
☐	Interprofessional collaboration (CAPE)
☐	Leadership (CAPE)
☐	Learner (CAPE)
☐	Medication use system management (CAPE)
☐	Patient advocacy (CAPE)
☐	Patient Centered Care (CAPE)
☐	Population-based care (CAPE)
☐	Problem solving (CAPE)
☐	Self-awareness (CAPE)
☐	Medication order entry (PTCB)
☐	Medication safety (PTCB)
☐	Pharmacology (PTCB)
☐	Pharmacy billing and reimbursement (PTCB)
☐	Pharmacy information systems (PTCB)
☐	Pharmacy inventory Management (PTCB)
☐	Pharmacy law and regulations (PTCB)
☐	Pharmacy quality assurance (PTCB)
☐	Sterile and non-sterile compounding (PTCB)
☐	Verbal communication skills (PTCB)
☐	Other Competencies. Describe: Click here to enter text.
15. Evaluation Methods Based on the gaps, educational needs, and desired results of this activity, what type of evaluation method(s) will be used to determine if the activity effectively met the needs of the participants and created the desired change in knowledge, competence, performance or patient outcomes? NOTES: Evaluating for change in knowledge and attitude only is not sufficient to qualify for continuing education credit. Evaluations must address changes in competence, performance or patient outcomes. A standard evaluation addresses effectiveness of faculty and intent to change (competence). Boston Children’s continuing education post-activity performance survey is used for all live activities and assesses if participants have made changes to their professional practice as a result of participation in the course. You are free to use an evaluation method of your choosing. Sample evaluation questions are included at the end of this application. You do not need to specify the questions as part of your application. Nursing Only: you must ask question(s) about the impact of the education on the nurses’ current or future practice.
☐☒	Knowledge and Attitude
☐	Knowledge focused post test
☐	Knowledge focused pre- and post-test
☐	Self-report of knowledge gain
☐	Other: Describe:
☐	Competence
☐	Post-activity test using case-based questions
☐	Pre- and post-tests using case-based questions
☐	Faculty written report of learner’s simulation activity results
☐	Faculty written report of observation of learner in the classroom
☐	Self-report of competence
☐	Intent to change statement
☐	Other: Describe:
Performance
☐	Faculty written report of observation of learner in patient care/workplace setting
☐	Chart audit data results
☐	Administrative database audit results
☐	Faculty written report of learner performance at hands-on skills workshops
☐	Self-report of performance (i.e. performance survey)
☐	Other: Describe:
Patient Outcomes
☐	Chart audit of health status measures with aggregate data provided to Boston Children’s Hospital
☐	Administrative data health status measures with aggregate data provided to Boston Children’s Hospital
☐	Local clinical or quality data provided to Boston Children’s Hospital
☐	Patient self-report of health status with aggregate data provided to Boston Children’s Hospital
☐	Other: Describe:
Healthcare Team
☐	Skills/Strategy
☐	Performance
☐	Patient Outcomes
☐	Other: Describe:
Describe how your planning team will obtain the evaluation data referred to above, compile it (aside from Boston Children’s post course survey) and analyze the data once it is collected. How will you use this data once it is analyzed?
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15. Budget Information: There are two sections to the budget. The first is the Activity Budget that collects information on all financial aspects of the course. The second section is an Honoraria Worksheet to identify who and how much honoraria each individual will receive. The Honoraria Worksheet provides an honoraria total that is incorporated (entitled “Honoraria total from Honoraria Worksheet”) in the Activity Budget. If any of the honoraria exceed the honoraria guideline provided (per the BCH DCE Honoraria policy), these amounts need to be justified fully in writing in the area after the Honoraria Worksheet for review and possible approval. If this doesn’t apply (internal programs with no revenue or costs), leave blank.
Sponsor	Hospital/Department	% income or deficit	Make income check payable to/send deficit invoice to (address and attention)	Financial Administrator (Name, phone, e-mail)
Primary:	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.
Partner #1:	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.
Partner #2:	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.
Fund Transfers Please provide your department ID and account number for fund transfers to cover costs associated with your course accreditation: Accreditation Cost (If applicable) Marketing Costs (If applicable): If you are marketing your course through Boston Children’s this is where printing, mailing, advertisement and list costs will come from. This information will also serve as the account you would like registration costs to be distributed to within 4-6 weeks of the course end date. *All charges will be sent to your course administrator/director for approval prior to the transfers being made.
Department ID:	Click here to enter text.
Account Number:	Click here to enter text.
Activity Budget: Income
$	Gross Tuition
$	Commercial Support (List Below)
$
$
$
$
$
$	Exhibit/Advertising Income
$	Income received from other sources (List Below)
$	Internal allocations from division, department or hospital
$	Grants from government or non-profits
$	Other income (hotel commission, etc.)
Income Total	$
Activity Budget: Expenses
$	Professional Services Fees
$	Course content management
$	Course logistics management
$	Other (describe)
$	Hotel/Meeting Site Costs
$	Participants food/beverage including tax and gratuity
$	Room rental
$	Complete audiovisual (projectors, ARS, microphones, etc.) and technical support
$	Faculty/Staff sleeping rooms cost including tax
$	Faculty/Staff meals, gratuities and tax
$	Other (describe)
$	Marketing and Meeting Materials
$	Printing
$	Postage and handling
$	Mailing lists
$	Syllabus and Course Materials
$	Other (describe)
$	Faculty and Staff-Related Expenses
$	Faculty travel-related expenses (airfare, in-transit meals, ground transportation, etc.)
$	Staff travel-related expenses (airfare, in-transit meals, ground transportation, etc.)
$	Business meals
$	Honoraria total from honoraria worksheet below
$	Certification Fees
$	Boston Children’s Accreditation Fee
$	Other (describe)
$	Other
$	FedEx/Courier services
$	Credit Card processing fees
$	Temporary Staff
$	Other (describe)
$	Expense Total
$	Net Income/Deficit after Expenses
Honoraria Worksheet Honoraria Rates Per the Boston Children’s Hospital IPCE Honoraria Policy*: Boston Children’s-affiliated Speaker: Recommended honoraria level not to exceed $500 per engagement Non-Boston Children’s Speaker Local, State-wide or Regional Audience (Presentation): Up to $2,000 Non-Boston Children’s Speaker National or International Audience (Presentation): Up to $2,500 Non-Boston Children’s Speaker National or International Audience (Keynote Address): Up to $3,000 *Honoraria that exceed the maximum listed above should be justified fully in the budget. The Director for Continuing Education will review extraordinary rate requests for possible approval, and may seek counsel from the Interprofessional Continuing Education Committee Leave blank if no honoraria.
Name	Individual’s Role	Honoraria Amount
Click here to enter text.	Click here to enter text.	$
Click here to enter text.	Click here to enter text.	$
Click here to enter text.	Click here to enter text.	$
Click here to enter text.	Click here to enter text.	$
Click here to enter text.	Click here to enter text.	$
Click here to enter text.	Click here to enter text.	$
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Honoraria Justification Use this section to justify any honoraria that exceed the guidelines provided in this document
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16. Approvals Please retrieve the following signatures for financial approval of this course: I authorize the development of this course by my department and agree to the financial policies outlined above. Leave blank if no financial considerations for your course (i.e., #15 is left blank)
Department Chair
Name:	Click here to enter text.
Email Address:	Click here to enter text.
Signature:	Date: Click here to enter a date.
Department Chair from Partnering Institution #1
Name:	Click here to enter text.
Email Address:	Click here to enter text.
Signature:	Date: Click here to enter a date.
Department Chair from Partnering Institution #2:
Name:	Click here to enter text.
Email Address:	Click here to enter text.
Signature:	Date: Click here to enter a date.
17. Commercial Support (JAC 9) Commercial Interest and Foundation Support Boston Children’s Hospital Philanthropic Support for Educational Events/Symposia from Corporations including the Pharmaceutical, Medical Device, & Life Sciences Industry Policy and Procedures: This policy and set of procedures applies specifically to corporate/commercial support from the pharmaceutical, medical device, and life science industry as it pertains to all educational events and symposiums (CME and non-CME) for the benefit of Children’s faculty and staff, Children’s patients and families, or the larger Longwood medical community. Both policy and procedures are meant to ensure compliance with internal policy and external regulations, specifically: The Policy on Philanthropic Activity, approved by Children’s Hospital Medical Center Board of Trustees (June 6, 1998) mandating that all fundraising activity on behalf of the Hospital be conducted by the Boston Children’s Hospital Trust; including gifts from individuals, foundations, corporations, and organizations. The federal Sunshine Act requiring corporations in the pharmaceutical, medical devices, and life sciences industry annually to report to the Centers for Medicare and Medicaid Services information regarding payments, ownership, investment interests and other transfers of value to physicians and teaching hospitals. NOTES: Any such support must be documented in an agreement among the supporter, IPCE and your institution, and signed prior to the activity. Any commercial support must be in compliance with the ACCME’s Standards for Commercial Support, which can be found at: http://www.accme.org/requirements/accreditation-requirements-cme-providers/standards-for-commercial-support Boston Children’s Hospital’s Conflicts of Interest Policy has several restrictions surrounding commercial interest support of certified educational activities that must be adhered to: A certified activity is prohibited from being supported by a single commercial interest. As such, acceptance of financial support from a commercial interest is contingent upon obtaining funding from at least one additional company. Each commercial interest must provide support at levels that are relatively equivalent (currently defined as no single funder providing more than 70% of the overall pool of commercial support for the activity) and no commercial interest can fund more than 50% of the costs associated with the activity. For example: A Course Director for an activity that has expenses of $100,000 may fund an activity’s expenses by accepting the following distribution of support: $50,000 of support from Pharma X (50% of budgeted expenses and 62.5% of the total commercial support obtained) $20,000 of support from Foundation Z (20% of budgeted expenses but this support is not included in the calculation of total commercial support as it comes from a non-commercial interest) $30,000 of support from Medical Device Company Y; Medical Device Company Y provided three devices to be used at the course with a value equivalent to 30% of the support. (30% of budgeted expenses and 37.5% of the total commercial support obtained) If an executed letter of agreement for the commercial support is not obtained prior to the start date of the IPCE activity, BOSTON CHILDREN’S will return the amount agreed upon in the letter of agreement to the commercial interest.
How will this activity be funded?
☐	Tuition
☐	Department/Organizational Funds
☐	Support from a foundation or commercial interest*. Such support may include funds or “in kind” support (e.g. equipment, supplies, space, etc.) *A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Providers of clinical service directly to patients are not considered to be commercial interests.
☐	Exhibitor or advertisement support
☐	Other: Describe:
Type of commercial support to be solicited:
☐	Not applicable. No commercial support will be solicited
☐	Educational Grant
☐	In-Kind Support (specify type below)
☐	Durable equipment
☐	Facilities/space
☐	Disposable supplies (non-biological)
☐	Animal parts or tissue
☐	Human parts or tissue
☐	Other, describe:
18. Exhibitor Support (JAC9) Exhibit and/or Advertisement Support Requirements regarding exhibit and advertisement support include: Arrangements for commercial exhibits or advertisements cannot influence planning or interfere with the presentations, nor can they be a condition of the provision of commercial support for activities. Product-promotion material or product-specific advertisement of any type is prohibited in or during activities. The juxtaposition of editorial and advertising material on the same products or subjects must be avoided. Live or enduring promotion activities must be kept separate from the activity. For live, face-to-face activity, advertisements and promotional materials cannot be displayed or distributed in the educational space immediately before, during, or after an activity. You must prohibit representatives of commercial interests from engaging in sales or promotional activities while in the space or place of the activity. For audio and video recordings, advertisements and promotional materials will not be included within the activity. There will be no “commercial breaks.” For computer-based activities, advertisements and promotional materials will not be visible on the screen at the same time as the educational content and will not be interleafed between computer “windows” or screens of the educational content. For print content, advertisements and promotional materials will not be interleafed within the pages of the educational content. Advertisements and promotional materials may face the first or last pages of printed educational content as long as these materials are not related to the educational content they face and are not paid for by the commercial supporters of the educational activity. Boston Children’s Hospital’s Conflicts of Interest Policy has several restrictions surrounding industry exhibits and advertising that must be adhered to: An industry-supported educational course must occur i) in a distant location, as approved in advance by the BOSTON CHILDREN’S IPCE Committee, and (ii) at a distinct time as a course approved for credit through Boston Children’s. All industry exhibits must be located in a separate room from Boston Children’s educational content so that participants do not have to interact with industry exhibitors unless they choose to do so. As appropriate, Boston Children’s courses must provide for reasonable and convenient access to food. All industry programs and/or exhibits must be marketed separately from the Boston Children’s activity. In other words, no co-promotion of Boston Children’s content and industry content should be permitted. Gifts from industry are prohibited in conjunction with Boston Children’s activities.
Will exhibits or advertisements be solicited?
☐	Yes
☐	No

If you need the Disclosure and Content Attestation Form, please contact any Interprofessional Education Committee member, or email continuingeducation@childrens.harvard.edu. Disclosure and Content Attestation Forms are required with the application, PRIOR to the educational activity.

Sample Evaluation Questions and Certificate are included at the end of this application for your convenience; you may use any format that aligns with your educational goals.

Sample Evaluation Questions

The certificate template is not required, as long as your certificate has the same statement as the one below.

All questions are required for Jointly Accredited Courses; if your course is not Jointly Accredited (interprofessional) please use all questions with the exception of #11-13. If you have any questions regarding evaluation of your course, please reach out to the CME Department at cmedepartment@childrens.harvard.edu or call (617) 919-9908.

Overall conference rating

Excellent

Good

Neutral

Fair

Poor

Please indicate whether the following conference objectives were met:

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Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Please evaluate only the sessions and workshops you attended:

Poor	Fair	Good	Very Good	Excellent
Quality of Presentation
Relevance to Practice

The format and educational methodologies engaged me in learning and were appropriate for the objectives and desired results.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

The content presented in this course was evidence-based.

o	Strongly Agree

o	Agree

o	Neutral

o	Disagree

o	Strongly Disagree

If you disagree, please explain:

The content was presented in an objective and balanced manner.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

If you disagree, please explain:

The content presented in this course was free of commercial bias.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

If you perceived bias, please explain: Click here to enter text.

Was disclosure information provided on all speakers and planning committee?

Yes

No

Will you make clinical, teaching, research, or administrative changes as a result of taking this course?

Yes

No

9a. If yes, what changes will you make? If not, why not?

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9b. If NO for above questions, why not/ (please check all that apply)

Current practice is satisfactory

I disagreed with recommendations made

Not confident enough in my ability to make needed changes

Lack of an implementation plan

Lack of time

Lack of staff resources

Lack of materials and tools

Lack of support for change by administration

Administrative/system costs

Care costs/insurance coverage

Patient barriers

Retired

Other (please specify)

Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
The educational activity helped to address, overcome, or remove barriers to change in my professional practice/activities.	☐
This course improved my understanding of interprofessional differences between nurses, physicians, pharmacists and other healthcare team members
This course improved my ability to work efficiently with healthcare team members who do not share my same title or professional training
Physicians, nurses, and other healthcare professionals could benefit equally from this course

Certificate of Completion

This certificate verifies that

Is hereby granted 0.0 (specify credit type here) for successfully completing

Program Name

Program Number

On Program Date

In support of improving patient care, Boston Children's Hospital is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing education for the healthcare team.