Maine Oesteopathic Association

Request for joint sponsorship and CME Accreditation


* - Indicates a required field (ALL fields are required)
* Conference/Program Title:
* Date(s) of Conference/Program:
* Course Location (auditorium/hospital/hotel...):
* Sponsoring Organization:
* MOA Affiliation/Relationship:
* Contact Name:
* Telephone:
* E-mail address:
* AOA CME Requested: 1-A 1-B 2-A 2-B

Category 1-A - Formal education program developed in concert with the Maine Osteopathic Association, with 50% of the presenters are osteopathic physicians, or MD's, PhD's, or other professionals with graduate degrees who hold a full-time faculty appointment at a college of osteopathic medicine,
   OR
Osteopathic physicians, or MD's, PhD's or other professionals with graduate degrees who hold a full-time faculty appointment at a college of osteopathic medicine, present 50% of the total educational hours.

Category 1-B - AOA accredited or approved hospital committee and departmental conferences with the review and evaluation of patient care, and conferences.

Category 2-A - Formal educational programs sponsored by non-AOA accredited and/or approved hospital committee and departmental conferences of an educational nature, such as tumor board and tissue committee conferences, hospital staff, departmental and division educational meetings.
* Hours Anticipated:
* Attendance Anticipated:
* Program Type: Formal Live Activity (lecture, symposium, seminar, workshop)
Standardized Life Support Program
Other (specify):
* Target Audience: MD/DO
RN
APRN/NP
PA
Other (specify):
Educational formats to be used (check all that apply) :
Small Group discussion/Panel Chart review/Recall Case presentations
Question and Answer Hands-on practice Videotape
Lecture Pre- and Post-tests Other (specify below)
Explanation of Educational Formats to be used:
*
Anticipated Registration Fee (list all) :
*
* Commercial Support: Yes No
If yes, list name(s) of commercial support organizations:
Please briefly explain what factors contributed to determining a need for the program topic:
*
What objective measures were used to establish need (if any):
*
What are the programs learning objectives:
(Note: Must be measurable learning objectives. Example: participant will learn the symptoms and preferred treatment methods for <topic>
*

Required documentation must be provided for this application:

  1. Draft or preliminary agenda including:
    1. Topics or presentation titles
    2. CV and Faculty disclosures for each presenter
    3. Start and finish times for all talks, breaks, lunches, etc.
  2. Draft copies of promotional materials, including web content.

Note: All final promotional materials must contain the accepted accreditation language provided by MOA application approval.
Under no circumstances may a brochure or flyer state "CME anticipated" or "CME applied for". The only exception to this is a Save the Date card, which may state that CME will be offered.

The application will not be considered, nor will CME credit be determined or awarded until the CME department receives all of the required documentation and a non-refundable application fee.
  

Required documentation can be emailed to info@mainedo.org or faxed or mailed with a non-refundable application fee to:

Dianne Jackson, Event Coordinator
Maine Osteopathic Association
693 Western Avenue, # 1
Manchester, ME 04351

Phone: 207-623-1101
Fax: 207-623-4228
Email: djackson@mainedo.org

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