Continuing Medical Education Application Form

Louisiana AAP Institute for Professional Education

Complete this form to submit your activity for consideration by the Louisiana AAP Institute for Professional Education.


Resources:




Is this activity part of an existing series?*

If this is a new series application, select no.

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Required for On-Demand (Enduring Material) Activities, Recommended for others.

Primary Contact for the Activity

Credits are assessed by the quarter hour and are subject to change following review of the agenda by CME Staff.

Do you want to offer maintenance of credit (MOC) or continuous credit for a subspecialty board?*

Additional fees may apply

Who can register for this activity?*
Is there a fee for participation?*
Would you like the LIPE to share this activity?*

Activity Details

What problem is happening? Where can we do better to reach optimal practice?

Why is the problem happening? What are the underlying factors contributing to this issue?

What do we want to change as a result of this activity in terms of learner competence, performance, and/or patient outcomes? What is the SMART goal we will use to know if the desired change has occurred?

Which providers will be included in this activity to effectively achieve the desired outcome?

Choose Teaching Strategies:

How can we deliver content to facilitate learning? How will we help learners build skills and/or performance?

Will this Activity be Online, In Person, or Hybrid?*
What format will the activity be in?*
Once this activity ends, will you repurpose the content into a different format for credit?*

Select all that apply

Identify Related Competencies:

What domains of professional practice (competencies) will be improved through this activity?

Identify Financial Relationships with Ineligible Companies:

ACCME Ineligible Company Definition


  • You will need to ensure all disclosure info is collected from all individuals affecting content (planners, reviewers, presenters, authors, staff, panelists, moderators, COI reviewers/mitigators and/or others who control educational content).


  • All disclosure information must be reviewed and mitigated by your designated conflict of interest (COI) mitigator before your activity launches. All documentation of this process must be submitted.


  • Disclosure information must be shared with learners, through an approved statement, before activity starts. Disclosures cannot contain corporate logo, trade name or product-group message of any ineligible company.


  • During activity development, the CME Department will work with you to address specific disclosure needs, review all disclosures for accuracy before launch.


  • Activities do not have an option to not award credit for a session/component that is missing or has unmitigated financial relationships


  • Any non-CME activities must have 30 minute interval separating them from a CME session that is occurring in the same educational space.

Include at least one mitigator per 10 individuals involved in developing content (speakers, planners, etc.)


Format: Name, Email

Will employees or owners of an ACCME-defined ineligible company be involved in this activity?*

This is prohibited except in very specific circumstances, if yes you will also need to fill out and submit an additional Employee COI form.

Insert the total number of individuals in control of content for this activity including speakers, planners, content developers, etc.

All financial relationships disclosed must include details about the relationship/topic being presented and added to the audit report

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include names and email addresses for all remaining planners, speakers, etc.

Activity Managers/Planners must ensure:


•    activities are developed independent of ineligible companies, an ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients


•    the following decisions were made free of the control of an ineligible company: identification of CME needs; determination of educational objectives; selection and presentation of content; selection of all persons and organizations that will be in a position to control the content of the CME; selection of educational methods; and evaluation and assessment of the activity


•    an ineligible company cannot take the role of a non-accredited partner in a joint provider relationship


•    everyone in a position to control the content of the activity has disclosed all financial relationships with any ineligible companies


•    financial relationships are all financial relationships, in any amount and within the past 24 months, that create a conflict of interest


•    all decisions related to the planning, faculty selection, delivery, and evaluation of education are made without any influence or involvement from the owners and employees of an ineligible company


•    disqualify any individual who refuses to disclose from being involved in a CME activity, that individual cannot have control of, or responsibility for, the development, management, presentation or evaluation of the activity


•    they have implemented a mechanism to identify and mitigate all conflicts of interest prior to activity launch


•    all disclosure information is shared with learners prior to activity launch via the AAP disclosure grid and must include the name of each person, name of all ineligible companies and nature of relationship each person has with each ineligible company; for people with no financial relationships, learners must be informed that no financial relationships exist; grid must contain a statement that all relationships have been mitigated


•    all activities should have a minimum of 1 of each of the following persons who disclosed included on your roster (if an individual serves in multiple roles, all roles should be listed): Staff, Planner, Presenter/Author, COI Reviewer/Mitigator

Financial Support

ACCME Ineligible Company Definition

Will this activity receive financial support (unrestricted educational grants) or in-kind support?*

Support from an ineligible company requires an agreement signed by the LIPE, the planning organization, and the ineligible company to ensure compliance with ACCME Standards. Additional fees will apply.

Include name of supporter, type of supporter, and either support amount or type of in-kind support

Include name of supporter, type of supporter, and either support amount or type of in-kind support

Include name of supporter, type of supporter, and either support amount or type of in-kind support

Activity Managers/Planners must ensure:


•    all commercial support associated with a CME activity is given with the full knowledge and approval of LA AAP


•    terms, conditions, and purposes of the commercial support must be documented in a written letter of agreement (LOA) between the ineligible company that includes the LA AAP and its educational partner(s)


•    LOA includes and is signed by the LA AAP, even if the support is given directly to the joint provider/educational partner


•    LOA specifies the ineligible company that is the source of support


•    both the ineligible company and LA AAP Director of Education sign the LOA in advance of activity starting/launching


•    have written policies and procedures governing honoraria and reimbursement of out-of-pocket expenses for planners, presenters, etc.


•    source of all support from ineligible companies is disclosed to all learners before the start of the activity (if support is "in-kind” the nature of the support must be disclosed)


•    disclosure information never includes the use of a corporate logo, trade name or a product-group message of the supporter


•    all decisions regarding disposition/disbursement of commercial support are made by LA AAP


•    LA AAP or our joint providers cannot be required by an ineligible company to accept advice or services concerning teachers, authors, or participants or other education matters, including content, from an ineligible company as conditions of contributing funds or services


•    only LA AAP, joint provider, or educational partner directly pay any teacher or author honoraria or reimbursement of out-of-pocket expenses in compliance with the LA AAP's written policies and procedures


•    no other payment is given to the director, planners, teachers or authors, joint provider, or any others involved with the activity, if teachers/authors are listed as facilitating or conducting, but participate in the remainder of an educational event as a learner, their expenses can be reimbursed and honoraria can be paid for their presenter/author role only


•    may not use commercial support to pay for travel, lodging, honoraria, or personal expenses for non-teacher or non-author participants of a CME activity. You may use commercial support to pay for travel, lodging, honoraria, or personal expenses for bona fide employees and volunteers of the LA AAP, joint provider or educational partner


•    must be able to produce accurate documentation detailing the receipt and expenditure of all commercial support

Advertising, Exhibits, & Promotion

All of the below must be kept separate from CME.


Note: If these take place in same room/screen as CME a 30-minute interval between the two is required. If learners must move/click to another space, event is not educational (ie a meal or guided yoga session), or would not cause any persons to have relevant financial relationships (ie committee update, business mtg, awards ceremony), then the 30-minute interval is not required. All non-CME components must be clearly labeled as such.


Full activity info with locations, or full access granted for online activities, will be submitted and reviewed to ensure non-CME sessions/ components are clearly labeled and do not take place in the same space as CME sessions or if they do take place in the same space, the 30 minute interval is in place.


Note: Advertising & exhibit income must be kept separate from financial support. Symposia and Product theaters are considered non-CME components and may not be accredited for CME credit.

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Advertising can be in programs and on event landing pages but may not be co-located with educational materials or in education spaces. All learners should be able to complete their learning without encountering advertisement.

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This includes names, emails, and other contact information. We recommend having a consent statement in the registration form if you will have exhibitors.

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These may include but are not limited to: educational activities that will not be submitted for CME credit, sessions planned by or with ineligible companies, product theaters, or other non-CME ancillary activities.

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Activity Managers/Planners must ensure:


•    education is separate from marketing or sales of products or services by ineligible companies —including advertising, sales, exhibits, and promotion—and from non-CME education offered in conjunction with education designated for CME credit


•    arrangements to allow ineligible companies to market or exhibit in association with a CME activity must not a) influence any decisions related to the planning, delivery, and evaluation of the education b) interfere with the presentation of the education or c) be a condition of the provision of financial or in-kind support from ineligible companies for the education


•    social events or meals at the activity do not compete with or take precedence over the educational event


•    while educating, planners/presenters must not actively promote/sell products or services that serve their professional/financial interests


•    names or contact information of learners are not shared with any ineligible company or its agents without the explicit consent of the learner


•    learners must be able to easily distinguish between CME content and other non-CME content/ activities, sessions/components that are part of the activity but are not designated for CME credits must be clearly labeled and communicated to learners as such


•    Marketing, exhibits, and non-CME education developed by or with influence from an ineligible company, or are planned and delivered by individuals with missing or unmitigated financial relationships, must not occur in the educational space within 30 minutes before or after a designated CME session/component


•    learners must not be presented with marketing while engaged in a CME activity, learners must be able to engage with the education without having to click through, watch, listen to, or be presented with product promotion or product-specific advertisement


•    educational materials that are part of the CME activity (such as slides, abstracts, handouts, evaluation mechanisms, or disclosure info) must not contain any marketing produced by or for an ineligible company, nor can they contain corporate or product logos, trade names, or product group messages (information distributed about the activity that does not include educational content, such as schedules and logistical information, may include marketing by or for an ineligible company)


•    ineligible companies may not provide access to, or distribute, any part of a CME activity to learners

Evaluation and Assessment

As a standard, Activities approved through the LIPE will be evaluated and assessed through the Learning Management System (LMS) provided by the Louisiana AAP, which will streamline evaluation and credit awards.


If you opt out of the LMS for your activity, additional fees and the following requirements may apply:


•    LA AAP Required Evaluation Questions must be included in all evaluation/assessment tools


•    MOC 2 activities must submit documentation that each learner met the MPS and all feedback provided to learners


•    Post activity, please share compiled evaluation data with planners and faculty

Will this activity be included in the Louisiana AAP Learning Management System?*

Activities will only be available for your learners unless other arrangements are discussed.

Will this activity include a post-test with feedback for Maintenance of Credit or Continuous Credit?

This activity may be eligible for ABP Lifelong Learning & SA (MOC Part 2) points:


•    I agree to abide by the policies described in the ABP Program Guide;


•    I attest that this activity meets all of the relevant requirements described in the ABP Program Guide;


•    I agree to allow ACCME to release information about this activity to ABP for its unrestricted use;


•    I agree to allow ACCME to publish information about this activity on its website as a service to learners;


•    I agree to comply with requests for information about activity if selected for MOC audit by ACCME or ABP;


•    I agree to collect required individual completion data and submit for ABP MOC credit via PARS, with permission of learners.


Activity Managers/Planners must ensure:


•    the content and format of a CME activity or its related materials promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company


•    content gives a balanced view of therapeutic options, using generic names will contribute to this impartiality, if educational material or content includes trade names, where available trade names from several companies should be used, not just trade names from a single company


•    all copyright permissions have been obtained, handouts don’t contain identifiable patient information, trade names, or logos


•    content is fair and balanced and any clinical content presented supports safe, effective patient care


•    all scientific research referred to, reported, or used in the activity in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation


•    educational content cannot advocate for unscientific approaches to diagnosis or therapy nor promote recommendations, treatment, or manners of practicing healthcare that are determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients


•    content that discusses, debates and explores new and evolving topics must be clearly identified as such within the program and individual presentations and cannot advocate for, or promote, practices that are not, or not yet, adequately based on current science, evidence, and clinical reasoning


•    Definition of CME: Continuing medical education consists of educational activities which serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession. The content of CME is that body of knowledge and skills generally recognized and accepted by the profession as within the basic medical sciences, the discipline of clinical medicine, and the provision of health care to the public.


•    Accreditation statements appear on all CME activity materials/brochures distributed for the activity, except for initial, save-the-date type announcements if such announcements contain only general, preliminary information about the activity such as the date, location, and title (if more specific information is included, such as faculty, objectives, and/or credit amounts, the accreditation statements must be included)

Agenda, advertisements, budget, etc.

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