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  1. Select a track

  2. Amount of time requested – 60 minutes, 75 minutes, 2 hours

  3. Intended learners

  4. Session description

  5. Expected value to meeting attendees

  6. Course director(s) name(s); years of experience

  7. Disclosures

  8. Expected learning outcomes

  9. Description of the professional practice gap (e.g. change in competence, change in performance and/or change in patient outcomes)*

  10. Describe the current state; describe the desired state; describe the identified gap (overall purpose of the activity):

    1. Choose educational need(s) that underlies the professional practice gap (e.g. knowledge, skills and/or practice)

·         Gap in Competence (knows)

·         Gap in Performance (knows how)

·         Gap in Patient Outcomes

·         Other - describe

  1. Desired learning outcome(s): What will the outcome be as a result of participation in this activity? (describe in terms of reflecting changes in competence, performance and/or patient outcomes). *

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  1. Scholarly, medical or scientific references

  2. Is this novel content that has never been presented before?*

21.  Learner Engagement

 

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  1. Course Director Disclosures

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