Needs Assessment:    What specific needs assessment data did you use to establish the need for this talk?

Example: Within the department, vaccination rates are below the national average.

Section wide survey indicated desire for additional CME in this topic.

Additional Needs Assessments include (please mark all that apply):

 Expert panels                                 Peer reviewed literature                       Research findings

 QA analysis                                    National clinical guidelines                  Specialty Society guidelines

 Database analyses                           Lay press                                          Other societal trends

Please list key data or references and attach documentation that support this need:

(Example: list department vaccination rate and attach Logician printout and list national vaccination rate and attach article or reference with vaccination guidelines or rates.)

Can attach survey findings here.

What specific Maintenance of Certification competencies will this talk cover? Please mark all that apply.

 Interpersonal and Communication               Medical Knowledge               Patient Care

 Practice-based Learning and Improvement    Professionalism                     Systems-Based Practice

Learning Objectives:  Please list what learners will be able to do after they participate in the activity? 

(Please refer to Writing Clear Learning Objectives tips sheet.)

At the conclusion of this activity participants will be able to:

Method:  Please check which education formats will be used during for this session (Mark all the apply)

 Lecture/Didactic session         Panel discussion                    Audio/videoconference         Case presentation

 Small group discussion            Laboratory experience            Pre/Post Test                        Workshops

 Other:       

Why is this method appropriate for your learning activity? How will this method assist you in accomplishing your stated objectives?

Will deliver content to audience.

Will any tools be provided to participants to assist with the changes in practice learned during this session?

 Patient education                   Patient reminder system                      Promotion of Self-Management

 Provider education                Provider reminder system                    Data Relay

 Audit and Feedback               Organizational change                         Other