AAOS CME Activity Planning Form

Financial Information C7, C8, C9, C10
Will this activity be receiving commercial support e.g., pharmeceutical or medical device company support? (The ACCME definition of commercial support is as follows: A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.) *

Yes No
If yes, please describe the type of support and the anticipated amount if available:

Commercial Support
If yes, please describe the type of support and the anticipated amount if available:
Other Anticipated Financial Support
In-Kind Support
Is another organization joint sponsoring or developing this activity?

Yes No
Additional Information
Administration: Choose all that apply.

The provider developed activities/educational interventions independent of commercial interests. (SCS 1,2 & 6). C7 The provider appropriately managed commercial support (if applicable, SCS 3 of the ACCME Standards for Commercial SupportSM). C8 The provider maintained a separation of promotion from education (SCS 4). C9 The provider actively promoted improvements in health care and NOT proprietary interests of a commercial interest (SCS 5). C10

Evaluation
Course Evaluation
Based on the outcome determined above (competence, performance or patient outcomes), indicate the evaluation method used to analyze changes in learners achieved as a result of the program's activities/educational interventions.
Please describe and/or attach. Choose all that apply. C11 *

CME evaluation form Group problem solving exercises Practice audits or chart reviews Performance evaluation such as direct performance evaluation or assessment on case based problems before and after activity Intent to change practice questionnaire
Please Attach Course Evaluation Questionnaire *
Should be Empty:

AAOS CME Activity Planning for Joint Providership of Educational Activities