APPLICATION FOR A CONTINUING EDUCATION ACTIVITY
All jointly provided activities undertaken by the Postgraduate Institute for Medicine (PIM) are
planned and implemented in accordance with the Accreditation Council for Continuing
Medical Education (ACCME) Criteria for Accreditation and all other accrediting body
requirements that may apply to this activity. Accordingly:
I.

PIM will be the final authority for all aspects of the planning process, including, but not limited to, the gap
analysis, learning objectives, activity design, faculty selection, and evaluation metrics.

All activities must comply with the ACCME Standards for Commercial Support, the FDA Final Guidance on
Industry-Supported Scientific and Educational Activities, and, if designed for physician learners, the AMA
standards regarding the Physician’s Recognition Award and Gifts to Physicians from Industry.

All activities must be for scientific and educational purposes only; the educational content of activities must
be accepted by the profession(s) constituting the target audience as being within the science/scope of practice
of the intended audience(s), and applicable to the provision of healthcare to the public.
Applicant
Organization
Tax ID
Address
City, State, Zip
Telephone
II.
Website
Primary Contact
Name
III.
Fax
Telephone
E-Mail
Personal Conflicts of Interest
List all individuals employed (or contracted) by your organization that are in a position to control
the content of this continuing education activity [identified individuals will be required to complete
a conflict of interest reporting form].
Name
Telephone
Planner/Manager
Fax
Name
Telephone
Name
Telephone
E-Mail
Planner/Manager
Fax
Other:
E-Mail
Planner/Manager
Fax
Other:
E-Mail
Other:
IV.
Proposed Activity
Title
A. Identify the general topic area to be discussed in the activity [i.e. cardiology,
oncology, women’s health, etc.].
B. Define the subject to be discussed in the activity [i.e. heart failure, leukemia,
depression, pain management, end of life care, etc.].
V.
Professional Practice Gaps and Educational Needs
A. What problems are you trying to solve? What are your learners doing that they
should NOT be doing; or, conversely, not doing that they SHOULD be doing?
Please briefly describe below:
PROFESSIONAL PRACTICE GAP ONE

Source/Citation(s):
B. In general terms, what education is needed to close this gap?
EDUCATIONAL NEED

C. Is the underlying need [double click the appropriate box(es)]:
Knowledge (understanding)
Competence (understanding + strategy about how to implement in practice)
Performance (understanding + strategy + implementation in practice)
V.
Professional Practice Gaps and Educational Needs (cont’d)
D. What problems are you trying to solve? What are your learners doing that they
should NOT be doing; or, conversely, not doing that they SHOULD be doing?
Please briefly describe below:
PROFESSIONAL PRACTICE GAP TWO [if applicable]

Source/Citation(s):
E. In general terms, what education is needed to close this gap?
EDUCATIONAL NEED

F. Is the underlying need [double click the appropriate box(es)]:
Knowledge (understanding)
Competence (understanding + strategy about how to implement in practice)
Performance (understanding + strategy + implementation in practice)
Attach Additional Sheets if Needed to Document More Gaps and Educational Needs
VI.
Intended Change
A. CME Activities must be designed for a potential outcome of changing competence,
performance, and/or patient health. Change in knowledge only is NOT an
acceptable outcome for CME. Activities intended for non-physician audiences
only may be designed for the potential outcome of changing knowledge. This
activity is designed to bring about a change in [double click the appropriate box(es)]:
Knowledge
VII.
Competence
Performance
Patient Outcomes
Learning Objectives
Based on the gap(s) stated above, list learning objectives for the activity that indicate what
you want the learner to be able to do upon completing the activity [i.e. each objective should
include a verb that describes an action by the learner (not what the teacher will teach)].
VII.
Learning Objectives (cont’d)
See Appendix A for a list of verbs for writing learning objectives. For example: Choose
appropriate induction therapy strategies for individual pediatric patients with acute
lymphoblastic leukemia; Use standardized, validated tools for cardiac risk assessment.





VIII. Target Audience
A. Indicate the profession(s) of the intended learner [double click the appropriate
box(es)].
Physician
Physician Assistant
Pharmacist
Registered Nurse
Nurse Practitioner/Other APRN
Psychologist
Social Worker
Healthcare Executive
Dentist
Other
B. If the audience includes physicians, what physician competencies will this activity
be designed to address [double click the appropriate box(es)]?
ABMS/ACGME - Patient Care and Procedural Skills
ABMS/ACGME - Medical Knowledge
ABMS/ACGME - Practice-based Learning and Improvement
ABMS/ACGME - Interpersonal and Communication Skills
ABMS/ACGME - Professionalism
ABMS/ACGME - Systems-based Practice
Institute of Medicine - Provide patient-centered care
Institute of Medicine - Work in interdisciplinary teams
Institute of Medicine - Employ evidence-based practice
Institute of Medicine - Apply quality improvement
Institute of Medicine - Utilize informatics
Other
VIII. Target Audience (cont’d)
C. Is this activity intended to be interprofessional continuing education, wherein an
interprofessional team (e.g. physicians and nurses; physicians and psychologists,
etc.) develops the content for presentation to members of the same professions,
emphasizing team-based, collaborative action?
Yes
No
D. If yes, what IOM interprofessional collaborative practice competencies is this
activity designed to address [double click the appropriate box(es)]?
Interprofessional Education Collaborative - Values/Ethics for Interprofessional Practice
Interprofessional Education Collaborative - Roles/Responsibilities
Interprofessional Education Collaborative - Interprofessional Communication
Interprofessional Education Collaborative - Teams and Teamwork
Other
IX.
Educational Design
A. Identify the format of the proposed activity [double click the appropriate box(es)].
Live Activity
Symposium
Lecture Series
Teleconference
Webcast
Simulation
Multi-day Conference
Skill Demonstration
Other
One-time Activity
Repeating Activity
Date(s)
Location(s)
Enduring Material
Internet
Newsletter
Monograph
Internet PoC
Podcast
Performance Improvement
Other
Planned Release Date
Journal-Based
IX.
Educational Design (cont’d)
B. Adult learners attain better results when they are engaged in their own learning.
What interactive method(s) will be used [double click the appropriate box(es)]?
Case Studies
Audience Response System
Q&A
Other
C. Provide a rationale for the educational format and/or methods chosen for instruction
See Appendix B for a list of educational formats and their rationale.
X.
Faculty Planning Leadership
A. Identify the potential Course Director (chairperson) and his/her affiliation.
Name
Title
Affiliation
B. List potential teaching faculty and their affiliations.
Name
XI.
Title and Affiliation
Type of Credit Desired
AMA (MDs, DOs, PAs)
ANCC (RNs, APRNs)
ACPE (Pharmacists)
APA (Psychologists)
ACHE (Healthcare Execs)
ADA (Dentists)
Other
Anticipated Number of Credits
XII.
Activity Support
List any potential commercial entities that could provide support for the activity.
Organization(s)
THIS COMPLETES THE APPLICATION PROCESS – THANK YOU!
Return Application to:
Postgraduate Institute for Medicine
Fax: (303) 858-8848
E-Mail: [email protected]
PIM Use Only
Date Received: _______________
via:
E-Mail
Fax
Mail
Approved for Providership
Provisional Approval, Pending: _________________________________________________
Denied, Reason: _____________________________________________________________
______________________________
PIM Clinical Staff Member
_______________
Date
APPENDIX A
VERBS FOR WRITING LEARNING OBJECTIVES
Some Verbs for Use in Stating Cognitive Outcomes
Knowledge
Define
List
Recognize
Record
Repeat
State
Comprehension
Explain
Express
Describe
Discuss
Identify
Restate
Translate
Application
Apply
Employ
Demonstrate
Illustrate
Interpret
Perform
Practice
Use
Analysis
Analyze
Appraise
Calculate
Categorize
Classify
Compare
Contrast
Criticize
Debate
Diagram
Differentiate
Distinguish
Outline
Synthesis
Arrange
Create
Design
Develop
Diagnose
Formulate
Hypothesize
Manage
Organize
Plan
Prepare
Propose
Summarize
Evaluation
Appraise
Assess
Choose
Compare
Decide
Estimate
Evaluate
Judge
Justify
Measure
Rate
Score
Select
Verbs for Use in Stating Affective Outcomes
Receiving
Accept
Ask
Choose
Follow
Reply
Show
Responding
Answer
Assist
Compile
Greet
Help
Valuing
Complete
Follow
Form
Initiate
Join
Share
Study
Organization
Adhere
Defend
Integrate
organize
Value Complex
Act
Discriminate
Display
Influence
Practice
Some Verbs for Use in Stating Psychomotor Outcomes
Perception
Detect
Differentiate
Identify
Set
Begin
Proceed
React
Respond
Start
Guided
Response
Copy
Follow
React
Reproduce
Mechanism
Assemble
Construct
Display
Manipulate
Work
Write
Complex
Assemble
Construct
Display
Manipulate
Operate
Work
Adaption
Adapt
Change
Revise
Vary
Origination
Arrange
Compose
Construct
Create
Design
Bad words that should not be used as cognitive objectives!
Increase
Know
Learn
Expand horizons
Really know
Thinks critically
Approach
Grasp the significance of
Appreciate
Improve
Become
Grow
APPENDIX B