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  1. Select a track

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

  3. Intended learnersLearners

  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)

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

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  • In reference to data, please provide a brief summary of data gathered that validates the need for this activity.

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  • Scientific evidence from the literature

  • Opinion from clinical or scientific experts

  • Information from the general public, the media, and/or other environmental sources

  • Observed performance

  • Data from local or national databases

  • Surveys from past participants or prospective learners

  • QI data

  • Other

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  • Didactic (lecture/presentations): Provide large amounts of information in a limited amount of time. Allows faculty to talk about chosen topictopics.

  • Case Study/Simulation: Provides an actual problem or situation an individual or group has experienced. An effective method of provoking controversy and debate on issues for which definite conclusions do not exist.

  • Audience Response (polling questions): Provides a simultaneous large audience respond response to faculty questions allowing faculty to chose choose from each response category to discuss the topic.

  • Panel Discussion/Debate: Provide an opportunity for experts or a group of learners to present differing viewpoints on a topic, issue, or problem to other panelists and the audience.

  • Question and Answer: Provides This provides an opportunity for faculty to answer specific participant questions and apply ways to implement it them in their practice.

  • Small Group (Breakouts): Provides and a less formal setting for peer interaction, discussion, and problem-solving.

 

  1. AGME/ABMS Competencies *Choose all that apply

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  • Values/Ethics for Interprofessional Practice

  • Roles/Responsibilities

  • Interprofessional Communication

  • Teams and Teamwork

  • N/A

 

  1. Scholarly, medical, or scientific references

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

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