715 Albany Street,
A305
Boston, MA 02118
P: 617.638.4605
F: 617.638.4905
www.bu.edu/cme
For Office Use Only
Course Code:
Max Credits:
Risk Credits:
Packet Checklist for Regularly Scheduled Series
Please fill out the top portion of this form and check off the items you include in the packet.
Return this form with your Regularly Scheduled Series (RSS) packet.
Course Coordinator
Title
Address
Phone
Fax
Please select the type of activity:
Email
Grand Rounds
Tumor Board
Case Conference
M&M
Title of Series:
For the entire series, please include:
A complete list of each session of the series that includes the following information: title, date, if commercial
support was obtained, and list of speakers and all others who were in a position of control for the educational
content of that session.
A typed alphabetical list of participants, including full names and degrees along with the total number of credit
hours attended. (Please note that the names and number of credits will appear on the certificate exactly as they appear on this list.)
For each session please include:
RSS Session Planning Form for each session with attachments. (Primarily for Grand Rounds)
RSS Risk Management Verification Form for each session that qualifies for Risk Management.
Promotional materials, which includes emails and flyers, must include proper CME language.
(Please see Promotional Material Checklist.)
If promotional materials were not distributed for any of the session please submit proof that the objectives
and accreditation statement were presented to the audience, either on the sign-in sheet or evaluation form.
Faculty Disclosure Forms completed by anyone in a position to control content of any of the sessions of a
series. (Please see Faculty Disclosure Guidelines)
How was disclosure information disclosed to the audience?
Forms next to sign-in sheet
Information printed on handout (please submit handout)
Completed Evaluation Forms for each meeting that occurred. (Please see our Evaluation Template.)
Handouts of the meeting (if applicable).
Original sign-in sheets
Did you receive commercial support* for any session of your series?
Yes
No
If yes, please note that you must provide the following documentation:
Signed Letters of Agreements (LOAs) with pharmaceutical companies and copies of checks (if
applicable). LOAs must be signed in advance of program by pharmaceutical company, course
director, and CME director.
How commercial support was acknowledged to the participants?
Included on handout or promotion
Made verbally
* Pharmaceutical lunches offered by pharmaceutical representatives are considered commercial support. The pharmaceutical company must send
support checks to the department who may then purchase lunch for participants. An LOA must be signed.
Please call the RSS Coordinator at 617-638-4605 with questions or concerns. We will be happy to assist you in anyway possible.