Canadian Society of Internal MedicineSociété canadienne de médecine interne

200-421 Gilmour Street, Ottawa, ON K2P 0R5Tel.: 613-422-5977 / Fax: 613-249-3326

Toll free: 1-855-893-CSIM (2746) info@csim.ca www.csim.ca

CSIM Application Form for MOC ApprovalApproval of Accredited Group Learning Activities:

Section 1 of the Framework of CPD Options of the Maintenance of Certification Program

Please ensure you are using the most recent MOC Application Form by clicking here to download. Applications submitted using an outdated application form will be returned.

Note that it is not permitted to advertise that an application for MOC approval has been made nor indicating that an activity is “pending approval” is strictly prohibited. For further information, please visit the Royal College website, list of FAQs, #5 .

Program Title:      

Location of Program:            City Province

Program Dates:            Start Date End Date

PART #1: ORGANIZATION REQUESTING APPROVAL (see definition on page 2)

Activities submitted for approval under Section 1 must meet the requirements for either Option A or B.Option A: Activities planned by a physician organization may be approved without being co-developed.

Option B: Activities planned by non-physician organizations must be co-developed by a physician organization or an accredited provider. If you have selected Option B, please do not complete this application and refer to the paragraph below on co-development and contact the CSIM Office.

If you do not meet the criteria in Option A or B, we will not be able to consider your application; the program is ineligible for Section 1 credits. Other options for obtaining credit exist for CPD activities that have not been reviewed or approved; please refer to the General Maintenance of Certification information on the Royal College website.

Co-Development: If you wish CSIM to consider a co-development program, please call the CSIM Office for more information regarding the process. The first step prior to submitting an application will be to provide a “Letter of Intent” outlining the project. The CSIM must have been involved in the planning process from the beginning. This includes program planning, planning committee selection, needs assessment, development of learning objectives, speaker selection, program implementation and evaluation. This constitutes educational co-development. For co-development, CSIM must be contacted before any planning commences. Note that a sponsor cannot take part in the planning process, be on the planning committee, select speakers nor be involved in the development of learning objectives.

Is the program sponsored by a physician organization (PO) (please refer below to the definition of a PO): Yes No

If yes: Name of the physician organization:      

Name of any non-physician organizations:      

Chair of the Planning Committee Requesting Approval:      (Name of Physician)

Address:      

City:       Province:       Postal Code:      

E-mail:      

Fax: (     )       Phone: (     )      

Contact person and email to copy correspondence:      

Page 1 of 8

Canadian Society of Internal MedicineSociété canadienne de médecine interne

200-421 Gilmour Street, Ottawa, ON K2P 0R5Tel.: 613-422-5977 / Fax: 613-249-3326

Toll free: 1-855-893-CSIM (2746) info@csim.ca www.csim.ca

Is this event online-only: Yes No

Is this a recurring activity*: Yes No List the number of times this activity will reoccur:      *A recurring event refers to an event occurring more than once within the 12 month accreditation period, with the same content, program, faculty, objectives, etc. for each occurrence. If there is any variation, each event must be accredited separately.

I have reviewed the Royal College Guidelines and process for physician organizations

NOTE: if a program is covering travel, accommodation or other personal expenses to participants, the program is not eligible for Section 1 credits. For further information, please refer to Section 32 of the CMA Guidelines for Physicians in Interactions with Industry (2007) and the Royal College interpretation which states: “All accredited group CME/CPD events cannot provide funding for physicians or their families to travel to attend events or to pay for their lodging or other related costs.”

Physician Organization: A not-for-profit group of health professionals with a formal governance structure, accountable to and serving, among others, its specialist physician members through:

Continuing professional development Provision of health care; and/or Research

This definition includes (but is not limited to) the following groups: Faculties of medicine Hospital departments or divisions Medical (specialty) societies Medical associations Medical academies Physician research organizations Health authorities not linked to government agencies Canadian Provincial Medical Regulatory Authorities (MRAs)

This definition excludes pharmaceutical companies or their advisory groups, medical supply and surgical supply companies, communication companies or other for-profit organizations and ventures/activities.

Types of organizations that are not considered Physician Organizations: Disease-oriented patient advocacy organizations (e.g. Canadian Diabetes Association) Government departments or agencies (e.g. Health Canada, Public health Agency of Canada) Industry (e.g. pharmaceutical companies, medical device companies, etc.) Medical education or communications (MEC) companies (e.g. CME Inc.) For-profit online educators, publishing companies or simulation companies (e.g. Medscape, CAE) Small number of physicians working together to develop educational programming

PART #2: MANDATORY EDUCATIONAL REQUIREMENTS

Criteria 1: The activity must be planned to address the identified needs of the target audience.

Please provide an explanation or supporting documentation for each of the following questions:

1. Who is the target audience for this activity? Please indicate specific specialties and, if applicable, indicate other health professionals for whom the activity is intended.     

2. Every accredited CPD activity must have a scientific/program planning committee that includes representatives of the intended target audience. List all members of the planning committee, their medical specialty or health profession, and indicate which are representing the physician organization?      

Page 2 of 8

Canadian Society of Internal MedicineSociété canadienne de médecine interne

200-421 Gilmour Street, Ottawa, ON K2P 0R5Tel.: 613-422-5977 / Fax: 613-249-3326

Toll free: 1-855-893-CSIM (2746) info@csim.ca www.csim.ca

3. What sources of information were selected by the planning committee to define the content of this activity? For example, reviews of the scientific or education literature; clinical practice guidelines; surveys or focus groups conducted by the sponsoring organization.     

4. Did the planning committee identify gaps in knowledge, attitudes, skills, or performance? For example, physician performance information from hospitals or provincial / national databases; self-assessment tests; case scenarios; quality improvement activities or audits of practice.     

Criteria 2: The activity must create learning objectives to address identified needs. The learning objectives must be printed in the program brochure/materials or in the online information and on the evaluation form itself (each objective should be rated individually). Objectives should clearly state what a participant will know or be able to do as a result of attending an event or session. Click here for information on developing learning objectives.

Please provide an explanation or supporting documentation for the following issues or questions:

1. Indicate the learning objectives for the overall event     

2. Learning objectives are required for each individual presentation and must be made available to participants before the session either in the printed program (preferred) or as a separate email, or posted online or as a handout distributed onsite. Please describe how participants will receive the session learning objectives.     

3. How were the identified needs of the target audience utilized in the creation/development of the learning objectives?     

4. Do the learning objectives express what the participants will know or achieve by participating in the activity? Yes No

5. How are the learning objectives linked to the evaluation strategies for the activity? For example, does the evaluation form list the learning objectives or pose questions to participants about whether the learning objectives were met?     

Criteria 3: At least 25% of the total education time must be devoted to interactive learning strategies.

Please send the proposed course schedule/program, outlining times, indicating discussion periods, workshops, small group sessions etc., and provide an explanation or supporting documentation for the following issues or questions:

1. What learning methods have been incorporated to promote interactive learning? For example, discussion periods, small group, workshops or seminars, audience response system?     

Criteria 4: The activity must include an evaluation of the event’s established learning objectives and the learning outcomes identified by the participants.

Please provide a copy of the evaluation tools developed for this activity. The evaluation form should include opportunities for the participant to identify what they have learned and its potential impact on stimulating further learning or for their practice (e.g.: Personal Learning Projects (PLPs); commitment to change). For information on evaluation, please click here.

Please provide a copy of the evaluation form and respond to the following questions:

Page 3 of 8

Canadian Society of Internal MedicineSociété canadienne de médecine interne

200-421 Gilmour Street, Ottawa, ON K2P 0R5Tel.: 613-422-5977 / Fax: 613-249-3326

Toll free: 1-855-893-CSIM (2746) info@csim.ca www.csim.ca

1. Do you provide an opportunity for participants to identify if the stated learning objectives were achieved?Yes: No: If no, please revise accordingly before you submit; note that each learning objective must be listed and evaluated separately.

2. Are there opportunities for participants to identify and/or reflect on what they have learned? (One example of this would be questions asking what the participants learned or plan to integrate into their practice)Yes No

Optional (3, 4 and 5)

3. Does the evaluation strategy intend to evaluate enhanced participant performance?Yes No If yes, please describe the tools or strategies used:      

4. Does the evaluation strategy intend to evaluate improved health care outcomes?Yes No If yes, please describe the tools or strategies used:      

5. Will the participants receive feedback related to their learning?Yes No If yes, please describe the tools or strategies used:      

PART #3: MEETING ETHICAL STANDARDS FOR CONTINUING PROFESSIONAL EDUCATION

Group Continuing Medical Education activities approved under Section 1 must meet the CMA Guidelines governing the relationship between physicians and the pharmaceutical industry.

If there is industry sponsorship, any financial assistance provided to reimburse physicians or their families for attending the program for travel or accommodation will result in non-approval for this application. For more information on the guidelines regarding Industry sponsorship, see the CMA Policy Physicians and the Pharmaceutical Industry (2007) (sections 21-40).

1. The physician organization must have control over the topics and content of the activity, as well as the speakers invited to present at the activity. We comply with this standard Yes No

Describe the process by which the topics, content and speakers were selected for this event:      

2. The physician organization must assume responsibility for ensuring the scientific validity, objectivity, and completeness of the content of the activity. We comply with this standard Yes No

Describe the process to ensure validity and objectivity of the content for this event:      

3. The sponsoring or co-sponsoring organization must disclose to participants all financial affiliations of faculty, moderators and members of the planning committee (within the past two years) with any commercial organization(s) regardless of its connections to the topics discussed or mentioned during the eventWe comply with this standard Yes No

IMPORTANT NOTE: Completed conflict disclosures from all speakers, faculty, planning committee members and moderators/facilitators are required prior to an event. Conflicts, or lack of conflicts, are to be disclosed on the second slide of the speaker’s presentation. The summary of conflicts of the planning committee/moderators are also to be disclosed and made available to event participants; this could be done via electronic/printed handout to participants; handouts available at the registration desk; or a summary posted online. Click here to view a sample summary.

a) Describe how conflict of interest information is collected:      

b) Describe how conflict of interest information will be disclosed to participants:      

Page 4 of 8

Canadian Society of Internal MedicineSociété canadienne de médecine interne

200-421 Gilmour Street, Ottawa, ON K2P 0R5Tel.: 613-422-5977 / Fax: 613-249-3326

Toll free: 1-855-893-CSIM (2746) info@csim.ca www.csim.ca

4. All funds received in support of this activity must be provided in the form of an educational grant payable to the sponsoring organization.

We comply with this standard Yes No

To whom has the Educational Grant been made payable:      

IMPORTANT NOTE: Accreditation statements cannot be located near any sponsorship recognition. Sponsorship recognition cannot be located within the scientific content. The accreditation statement is to be located within the program. Signage with sponsor recognition cannot be located within the room where the educational activity is taking place.

Please include a copy of the detailed budget for this program that identifies each source of revenue and each expenditure for this event. Please describe how the physician organization(s) assumes responsibility for the distribution of these funds, including the payment of honoraria to faculty.      

Name of organization issuing any honoraria:      

Please identify all organizations that are funding this activity. If necessary please use an additional page.     

5. No drug or product advertisement may appear on or with any of the written material for this event. We comply with this standard Yes No

6. A) Generic names should be used on all presentations and written materials. If trade names are used they should be accompanied by the generic name.We comply with this standard Yes No

B) Describe the process to advocate speakers’ adherence to using generic names of medications and/or devices included within all presentations or written materials.     We comply with this standard Yes No

ONLINE EVENTS ONLY:

1. Is this activity online? Yes No

2. Does the program comply with the Criteria for approval of Online CPD Events for Maintenance of Certification described by the Royal College? Yes No

3. Asynchronous group learning activities delivered via the web must provide an opportunity for interaction between participants and course faculty/facilitators and enable participants to observe the interaction of other participants with the course faculty/facilitator. Please describe how this will be achieved:      

4. Participants must ‘log on’ to the interactive component to claim credit under Section 1. Please describe how this will be achieved:      

5. Certificates of completion should only be given to participants after they have ‘logged on’ to the interactive component for the course. Please describe how this will be achieved:      

Page 5 of 8

Canadian Society of Internal MedicineSociété canadienne de médecine interne

200-421 Gilmour Street, Ottawa, ON K2P 0R5Tel.: 613-422-5977 / Fax: 613-249-3326

Toll free: 1-855-893-CSIM (2746) info@csim.ca www.csim.ca

DOCUMENTATION REQUIRED: ALL documentation must be included with your application to form a complete application. Applications are to be submitted at least 8 weeks before program start date. Incomplete applications will not be accepted and may occur extra administration fees. Each item is to be sent as its own file in Word or PDF format. Indicate if you have included the following documentation:

Completed application form emailed to info@csim.ca Yes No

Detailed program Yes No

Evaluation summary of this program from last year Yes No 1st time the event has taken place

Learning objectives for each presentation Yes No

*Detailed budget and sponsorship information (Revenue sources and expenses need to be itemized) Yes No

(Budget example) *ALL applications must use this budget template. A copy of the evaluation form (each presentation is to be evaluated) Yes No (Evaluation example)

A copy of the information/confirmation email/letter sent to speakers Yes No

Completed conflict disclosures for all faculty/speakers, moderators, and planning committee members Yes No

Please name files consistently and clearly (“Smith_John_COI.pdf”) Conflict disclosure summary (Summary example) Yes No

Copy of the certificate of attendance/participation Yes No (Certificate example)

Needs Assessment (e.g.: survey/questionnaire results) Yes No

Application Fee Yes No

I have informed/will inform speaker(s) to disclose any conflicts in their 2nd slide. If there is nothing to disclose, this

should also be stated Yes No (Disclosure Example)

For online programs only, I have reviewed the document Criteria for approval of Online CPD Events for Maintenance of

Certification and agree that the program complies with the standards described Yes No

For co-developed applications only: a copy of the minutes of the planning committee Yes No

For co-developed applications only: the completed co-development checklist and initiation form Yes No

DECLARATION: As the course planner I accept the responsibility for the accuracy of the information provided in response to the questions listed on this form and, to the best of my knowledge, certify that the CMA’s guidelines, entitled “Physicians and the Pharmaceutical Industry (2007) (sections 21-40) have been met in preparing for this CPD event.

I confirm that the required documentation is complete and attached.

I have reviewed the CSIM document “The Role of the Canadian Society of Internal Medicine in the Approval and Co-Development of CPD Activities” located on the CSIM website www.csim.ca.

Chair of the planning committee:      

Print name:       Signature:      

Date:      

Page 6 of 8

Canadian Society of Internal MedicineSociété canadienne de médecine interne

200-421 Gilmour Street, Ottawa, ON K2P 0R5Tel.: 613-422-5977 / Fax: 613-249-3326

Toll free: 1-855-893-CSIM (2746) info@csim.ca www.csim.ca

NOTE: Applications will not be reviewed until all documentation and fees are included. The date of review commences on the date the full and complete application is received. The application fee is non-refundable even in the event the application is declined. If the application is approved, this fee will be applied to the full accreditation fee.

In order to give CSIM the opportunity to adequately review your program and make any suggestions for improvement, please submit your application as soon as possible in advance of the event. Please allow up to eight (8) weeks for Section 1 review and approximately six (6) months for co-development applications. Please allow six to eight (6-8) weeks to consider a co-development proposal.

It is not permitted to advertise that an application for MOC approval has been made and indicating that an activity is “pending approval” is strictly prohibited. For further information, please visit the Royal College website, list of FAQs, #5.

Applications submitted four weeks from the start date of the program may be rejected. Upon exception, the application may be reviewed as a rush and an Expedited Accreditation Fee will be applied. If you have a rush application, please contact the CSIM prior to submission of the application.  Note that for rush applications, there will be no refunds of the accreditation fee or rush fee. Applications submitted three weeks or less from the start date will not be considered. Co-developed programs are not eligible for expedited review. 

FEE STRUCTURE

PROVIDERACCREDITATION PROCESS

(Section 1 and Section 3)FEE NON-REFUNDABLE

APPLICATION FEE*

Physician organizationNo funding for the event Section 1 Approval

$750(plus HST)

$200(plus HST)

Physician organization With funding for the event Section 1 Approval

$1,250(plus HST)

$500(plus HST)

Physician organization Section 3 Approval$1,250

(plus HST)$500

(plus HST)

Non-physician organizationEducational co-development where CSIM would be represented on the planning committee from the onset of planning.

$8,000Plus a $2,000 Administration fee.

Plus $300 for each recurring event.

If additional funding agreements are required:

Grant Administration fee: $1,500 each

(taxes apply to all fees)

$1,000(plus HST)

Note: Additional fees may apply for changes relating to the application and invoicing process as well as for additional requirements relating to funding/program administration.The non-refundable application fee must accompany the application (if approved, this fee will be applied to the full accreditation fee)

*APPLICATIONS FOR CO-DEVELOPMENT CONSIDERATION: Please include a non-refundable application fee of $1,000 for consideration of co-development applications. Should your application be approved, the application fee will be applied to the accreditation fee. No planning can commence until the funds have been received. In the event that a co-developed activity does not take place after the planning has commenced, there will be no refunds of any fees including the application fee, administration fee and accreditation fee. Refer to page 1 for more information regarding co-development and to CSIM’s document entitled “The Role of the Canadian Society of Internal Medicine in the Approval and Co-Development of CPD Activities” for more information.

The completed application and documentation is to be sent electronically to info@csim.ca.

The applicant should keep an electronic copy of the completed application form and submitted documentation.

Page 7 of 8

Canadian Society of Internal MedicineSociété canadienne de médecine interne

200-421 Gilmour Street, Ottawa, ON K2P 0R5Tel.: 613-422-5977 / Fax: 613-249-3326

Toll free: 1-855-893-CSIM (2746) info@csim.ca www.csim.ca

The non–accredited provider has the responsibility for maintaining and documenting an ethical relationship with industry supporters; maintaining records of the evaluations and participation rests with the non-accredited provider.

NOTE: Section 1 approval is valid for 12 months.

GENERAL INFORMATION Applications may NOT be submitted after an event. Applicants should keep a list of their attendees for record purposes for a period of five (5) years. The non-accredited provider is to maintain records of CPD activity (materials, attendance) and submit information to the

Validation Program on request by the Royal College. General Maintenance of Certification information can be found on the Royal College website. Notice of approval of this activity will be forwarded to the Royal College of Physicians and Surgeons of Canada in order

to list your event on the Royal College web site. The College will also be notified of applications that are declined. Click here for the Royal College Accreditation Tool Kit . Guidelines for Accredited Providers of CPD Activities .

SELF-ASSESSMENT PROGRAMS (SAPs) For a copy of CSIM’s SAP Application Form, please click here or visit www.csim.ca. Click here for Royal College information on self-assessment programs

SIMULATION ACTIVITIESFor a copy of CSIM’s Simulation Activity Application Form, please click here or visit www.csim.ca. Click here for Royal College information on accredited simulation activities

The non-refundable deposit must accompany your application form.

I have sent a cheque to CSIM for: Deposit Full fee Please email an invoice.

Please advise the CSIM office promptly if you do not receive a Notice of Receipt of Submission within 48 hours of submission. It is the applicant's responsibility to ensure the completed application is received.Please allow six to eight (6-8) weeks to consider a co-development proposal.

CSIM CPD SUB-COMMITTEE MISSION STATEMENT“Our ultimate goal is to go beyond the simple transmission of information. Our goal is to make a

lasting impact on the knowledge, skills and attitudes of clinicians and future clinicians; to narrow the theoryto practice gap; to improve the health of our patients and of all Canadians.”

September 9, 2016

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