Application for Co-Sponsorship without CME

A co-sponsorship agreement without CME is one whereby the submitting organization is an ACCME Accredited Provider responsible for the educational integrity of the program. ASE will endorse the educational activity, but assumes no CME responsibility; the submitting organization is responsible for providing CME and ensuring that the activity is conducted in accordance with all ACCME guidelines and policies.

Instructions for Completing the CME Application
Program planners are urged to complete the CME application at least six months prior to printing brochures or other course documents. A preliminary program brochure containing a complete agenda with invited faculty must be submitted with your application.

Please return the application with the requested documentation attached, along with the application fee to ASE. Applications will not be reviewed unless all requested documentation is included. Payment must be received prior to review.

You will receive written confirmation that your application has been received at ASE. Applications are reviewed by the CME staff for completeness. Incomplete applications will be returned to you with a checklist requesting the missing information. Complete applications are circulated to the Review Committee for determination of cosponsorship. The Committee requires at least 10 business days for review of an application. You will be notified, in writing, of the Committee's decision. ASE reserves the right to deny co-sponsorship of any activity without cause. No materials may be printed using the ASE name and/or logo until the program has been approved and the materials have been individually reviewed and approved. All promotional materials for ASE co-sponsored educational activities must be approved by ASE staff in writing prior to printing and distribution.

Pre-Activity Requirements
• The completed ASE co-sponsorship application, including attachments, should be submitted to the ASE CME Office at least six months prior to distribution of promotional materials.

• At least 10 business days are required for review of a submitted application. This estimate of time may change due to application volume. ASE reserves the right to deny any application for sponsorship without cause.

• Under no circumstances may the ASE name and/or logo be used to promote an educational activity prior to receipt of written approval of ASE co-sponsorship.

• Upon receipt of written approval of ASE co-sponsorship, a signed letter of agreement should be returned to the ASE CME Office no later than 15 business days after receipt

• All printed materials must be reviewed and approved by the ASE CME Office prior to printing and distribution.

• At least 30 days prior to the start of the activity, the course planner should provide ASE with a mailing address for shipment of ASE's educational materials, which will be made available to attendees onsite at the program.

Co-Sponsorship Package Selection*

Basic Marketing Package - $1,000 Regional Marketing Package - $2,250 Standard Marketing Package - $3,000 Extended Marking Package - $5,500

Information on the Submitting Organization
A letter of approval from the primary sponsor and any other sponsoring institutions is required and must accompany this application

Name of Primary Sponsor:*

Contact First Name:*

Contact Last Name:*

Billing Address:*

City:*

State:*

Zip Code:*

Email:*

Phone:*

Fax:

Expiration date of your ACCME Accredited Provider term:*

Additional Sponsors

Additional Sponsor (if any):

Relationship to Submitting Organization
(i.e.: course is being offered in cooperation with)

Contact Name:

Title

Billing Address:

City:

State:

Zip Code:

Email:

Phone:

Fax:

General Course Information

Title of Program:*

Target Audience(s):*

Date(s) of Program:
Dates must be fully outside of ASE's black-out policy. Contact ASE staff if you have any questions regarding blackout dates or policy as found on the website.

Start Date*

End Date*

Location (Facility and City/State):*

Number of AMA PRA Category 1 Credits (CME Hours) being offered by the Primary Sponsor:*

Projected Overall Attendance:*

Registration Fees:
ASE Members are to pay no more than 80% of the non-member fees.

ASE Physician/Scientist Member: $740
Non-Member Physician/Scientist: $930
ASE Non-Physician Member (Cardiovascular Sonographer/Nurse/Student): $595
Non-Member Non-Physician (Cardiovascular Sonographer/Nurse/Student): $745

Commercial Support

Will this program have a commercial support?*

Yes No

If yes, how do you plan on providing proper recognition and disclosure of supporting companies?

Educational Content

Learning Objectives (minimum of 5 required)*
At the end of the program, participants will be better able to:

Course Description:*
Please write a 1-2 paragraph course description indicating the educational content to be presented, the format of the presentation(s), and instructional methodology. This should be the program description used in your brochure and onsite syllabus.

Course Content:*
Please describe how the content of your course relates to the current or potential scope of practice of ASE members and learners.

CME Activities
CME activities should be developed in the context of desirable physician attributes. Please indicate which of the ACGME/ABMS or IOM core competencies will be addressed in this activity.

Patient Centered Care:

(Identify, respect, and care about patients' differences, values, preferences, and expressed needs; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health.)

Medical Knowledge:

(Established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social behavioral) sciences and the application of this knowledge to patient care.)

Practice Based Learning and Improvement:

(Involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.)

Professionalism:

(Commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population.)

System-Based Practice:

(Actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.)

Interdisciplinary Teams:

(Cooperate, collaborate, communicate and integrate care teams to ensure that care is continuous and reliable.)

Quality Improvement:

(Identify errors and hazards in care: understand and implement basic safety design principles such as standardization and implications; continually understand and measure quality of care in terms of structure, process and outcomes in needs; and design and test interventions to change processes and systems of care, with the objective of improving quality.)

Utilize Informatics:

(Communicate, manage knowledge, mitigate error, and support decisions making using information technology.)

Employ Evidence-Based practice:

(Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible.)

Interpersonal and Communication Skills:

(That result in effective information exchange and teaming with patients, their families and other health professionals.)

What teaching methods will you be using?

Didactic Lecture

Hands-on Workshop

Case-Based Discussion

Self-Assessment Tools

Audience Response System

Question-and-Answer

Panel Discussions

Video

Small Group Breakout Sessions

Patient Demonstrations

If checked, please explain below.

Other

Other:

Faculty
A CV and current disclosure information for all program chairs and/or co-chairs MUST be included with the application. ASE requires that at least the Program Chair must be a current member of the Society.

Program Chair/Content Developer:

Name:*

Degrees:*

Title:*

ASE Membership #:*

Affiliation:*

City/State:*

Co-Chair #1 (If applicable):

Name:

Degrees:

Title:

ASE Membership #:

Affiliation:

City/State:

Co-Chair #2 (If applicable)

Name:

Degrees:

Title:

ASE Membership #:

Affiliation

City/State

Other Faculty (include name, degree, title, affiliation, city and state):
CV and disclosure information for faculty not involved in the planning process does not need to be provided with the application.

How do you plan on making the audience aware of the faculty afflictions and any conflicts of interest/disclosures?*

Printed Materials
It is required that you submit a copy of all brochures, flyers, syllabi and other written material for this program to the ASE CME Office prior to printing for our review and approval. The ASE logo must appear on the front and back of all materials with the following statement "Co-sponsored by the American Society of Echocardiography."

How will this activity be premoted?
**Must adhere to ACCME Guidelines on advertising

Mailed Brochure

Printed Advertisements

Email Invitations

Save-the-Date Cards

If checked, please explain below

Other:

Will you be purchasing a copy of the ASE membership list?*

Yes No

Will you be distributing a printed syllabus for this activity?*

Yes No

Post-Activity Requirements
ASE requires that final drafts of the following items be kept on file in our office for all ASE sponsored educational activities:

• Two (2) copies of all promotional materials, including save-the-date cards, registration brochures, etc.

• Two (2) copies of all handouts and/or syllabus materials provided to attendees onsite.

• One (1) electronic copy of the final faculty and attendee list, including name, address, phone, and email contact information.

• One ( 1) electronic copy of the final summary of the attendee program and faculty evaluation.

Copies of the above items should be on file in the ASE office within two months of the completion of the educational activity.

NOTICE: File Attachments
Once you click "Submit", you will be asked to upload your REQUIRED application materials. This should include the following items:

1. A Preliminary program brochure containing a complete, hour-by-hour agenda with invited faculty for each date of the program.

2. A copy of the Attendee Program & Faculty Evaluation attendees will use to evaluate the effectiveness of the educational content and the faculty presenters.

3. Previous Year's Evaluation Summary (for annual events)

4. Chair/Co-Chair CV's & Disclosure Information

Agreement
I hereby certify that the above statements are correct and complete. As Course Director, I certify that a proposed budget for this meeting has been submitted to and reviewed by the sponsoring organization, and agree to display and make available onsite to attendees ASE educational materials, which ASE will provide. If the educational program includes industry exhibits, I agree to offer ASE complimentary space if requested. I understand that I am required to send ASE the final faculty and attendee list including name, address, phone and email, within 2 months of the completion of the education activity. I understand that ASE does not certify that attendance at an ASE co-sponsored course guarantees competence or proficiency in the performance and/or interpretation of cardiovascular ultrasound. I understand and agree that if this course is approved for ASE co-sponsorship, ASE assumes no financial obligation to this course; all expenses incurred by this activity are the responsibility of myself and/or the sponsoring organization.
I understand that the co-sponsorship application fee is non-refundable and submission of this application does not imply course sponsorship by ASE; the sponsorship decision is at the sole discretion of the American Society of Echocardiography.

Applicant Signature*

Date Signed*

Send me a copy of my responses

Email address