SFNS Continuing Medical Education Activity Worksheet (page 1 of 4)Activity Name:

If part of a larger symposium, then name of the symposium:

Activity Date, Time, & Place:

Speaker Name and Contact Info:

Submit completed CME Activity Worksheet form to the Executive Director no later than 30 days prior to the program. The application must include:

• CV (or resume) for each speaker• Documentation of how the need for this program was identified

Faculty Disclosure Form must be completed by all speakers. Attendees at the program must be made aware of the disclosures (even if the individuals have indicated they have nothing to disclose) so that each participant may personally evaluate the objectivity of the information presented. Disclosure is made to the attendees by verbal announcement during the introduction of the speaker(s).

Verbal Disclosure Form must be signed by President, Moderator or CME Chair, to verify that a verbal disclosure was given.

All potential conflicts of interest must be identified and managed prior to the CME activity by using the “Resolution of Conflict of Interest Form”.

Essential Area #1� CME activity is consistent with the SFNS mission statement

San Francisco Neurological Society CME Mission Statement

The San Francisco Neurological Society (SFNS) CME program is committed to the continuing medical education of its members, designed to improve and enhance critical thinking and analysis of the latest neuroscientific information, to help promote innovation in the basic sciences, and to increase competence and improve practice performance and thereby patient care in the clinical sciences. This is accomplished by providing diverse, advanced, relevant, judicious, challenging and sometimes controversial information in the neurosciences, provided through didactic programs and scholarly debate.

Purpose: The purpose of the SFNS CME program is to provide high-quality, evidence-based educational opportunities that are designed to advance physician competence, enhance practice performance, promote optimal patient care, and to provide the latest neuroscientific information in a forum which encourages critical thinking and debate, and which fosters innovation and creative thinking for further research and academic pursuit.

Target audience: The SFNS CME program targets neurologists, neurosurgeons, neuropsychologists, nurses, residents, radiologists, and other medical professionals interested in research, improvement in patient care, and clinical advances in the neurosciences.

Types of Activities Provided: As a CME provider for healthcare professionals ranging from research and academia to clinical practice and to associated neurosciences, our CME activities include conferences, symposia, seminars, debates, clinical presentations, research presentations, and other possible forums. The educational design, instructional method and learning format for each event is chosen to best serve the educational needs and learning objectives of the planned

SFNS Continuing Medical Education Activity Worksheet (page 2 of 4)

educational activity. The SFNS CME activities offered range from one hour dinner programs to longer symposia of one or more days in length.  The activities presentation methodology may include a one person lecture with power point slides, interactive demonstrations, panel discussions, or breakout groups.  The SFNS currently holds only live CME activities, but provides accompanying enduring printed materials.

Content: Included in the SFNS educational offerings are updates on diagnosis and management of neurological and neurosurgical diseases, information on disease prevention, cultural/sexual/linguistic specific issues, information designed to improve communication and practice procedures, issues related to professional development in bioethics, leadership, and patient safety, and advances in neuroscience research to promote better understanding of neurological disease.

Expected Results: The expected result of the SFNS educational activities is that participants increase their competence in the subject areas and their ability to apply their knowledge and skills to improve practice performance in their field, and where appropriate, to improve ability to assess relevant research and apply this toward advances in the neurosciences. Educational activities are evaluated by the participants and by the CME committee. Results are summarized for review and analyzed by the CME Committee. The CME Committee measures the impact of the educational activity, determines which expected results have been achieved, identifies remaining gaps, establishes needs and plans for future programs, including ways of assessing future program results.

Essential Area #2 CME activity addresses needs that were identified through needs assessment data that were collected by (check all that apply):

� program evaluations from target audience

� peer review

� Faculty perception

� consensus of experts

� other (describe) ________________________________________

Documentation showing how the need was determined (such as survey results, evaluation data, committee minutes, or other material) need to be attached and submitted in the CME program file.

� This CME activity has:

� up to 3 educational objectives

� a description of overall course educational content

� identified target audience

� has content that matches the learners’ current or potential scope of professional activities

� been developed independent of commercial interests

� a mechanism to make objectives known to participants (brochure, website)

Copy of program flyer must be submitted in the CME program file

SFNS Continuing Medical Education Activity Worksheet (page 3 of 4)

� Educational format and methods to be used (check all that apply)::

� lecture � formal discussion period

� case presentation � panel presentation

� film or slide projections � handouts

� other __________________

Essential Area #3� This CME activity will:

• Evaluate the effectiveness of its CME activities via the distribution of onsite evaluation forms

• Summarize the evaluations forms within 60 days

• Survey attendees 90 days after program via online survey to evaluate how the program, if any, has met educational needs

• CME Committee will meet after results of online survey to evaluate the changes in learners, effectiveness of its overall CME program and determine where improvements need to be made

What Competencies were used for planning this CME activity:

� Patient Care

� Medical Knowledge

� Practice Based Learning and Improvement

� Systems Based

� Professionalism

� Interpersonal Skills and Communication

EDUCATIONAL GRANTS

If educational grants are secured, financial support will be acknowledged in the meeting brochure or other onsite materials along with a statement that the content of the presentation is solely the product of the SFNS and/or the speaker. Grants to offset legitimate educational meeting expenses, coffee breaks, meals, receptions are permitted. Financial subsidiaries from corporation to attendees are NOT permitted.

Cultural and Linguistic Proficiency Policy Conforming with AB 1195 Guidelines

SFNS Continuing Medical Education Activity Worksheet (page 4 of 4)Element 3.2.1The provider must be in compliance with all California State laws regarding continuing medical education, including Assembly Bill 1195, effective July 1, 2006.

Provider meets or exceeds minimum requirements of AB 1195 by the following:

a) Acknowledge within their CME mission statement the importance of culture and communication for delivering effective health care and establish a commitment to educate physicians to deliver culturally and

linguistically appropriate care.

b ) Assess for each planned CME activity any evidence of health disparities that have been linked to cultural or linguistically related practice gaps (i.e. physician knowledge, competence, or performance) found within the relevant physician learners/patient community. If no cultural or linguistic health or health care disparities or practice gaps are identified, this should be documented.

c ) Generate at least one educational component for each activity that addresses a specific need underlying the identified cultural/linguistic competency-based quality gap.

d ) Incorporate appropriate assessment tools for each cultural/linguistic component, and evaluate any changes/improvements that occur as a result.

Name of person submitting form:

Signature: