ࡱ> %` bjbjNN ^,,&3///801Lz\26.0606067xY;5=x x x x x x x$m|h~Dx%>7"7%>%>Dx0606=y D D D%>\0606x D%>x D Dpl"u06P2 rmv/@|Fr*vDyzprs@sT"us"u%>%> D%>%>%>%>%>DxDxCj%>%>%>z%>%>%>%>)//  SAP Application Form Approval of Accredited Self-Assessment Programs Section 3 of the Framework of CPD Options of the Maintenance of Certification Program The standards contained within this application must be met and supporting documentation provided in order for a Self-Assessment Program to be approved under Section 3 of the MOC program. The Canadian Dermatology Association, as an authorized accredited provider for the Royal College of Physicians and Surgeons of Canada, will determine if your program meets these standards. Self-Assessment Program Title:  FORMTEXT       Name of Developing Organization:  FORMTEXT       Self-Assessment Programs approved under Section 3 must be developed or co-developed by a planning committee consisting of members of a physician organization (see definition below). Physician Organization: A not-for-profit group of health professionals with a formal governance structure, accountable to and serving, among others, specialist physicians through: *Continuing professional development; *Provision of health care; and/or *Research This definition includes (but is not limited to) the following groups: Faculties of Medicine Hospital Departments or Divisions Medical Societies Medical Associations Medical Academies Health branch of the Canadian forces This definition excludes pharmaceutical companies or their advisory groups, medical supply and surgical supply companies, communication companies, or other for profit organizations and ventures/activities. Please select the option that applies to your organization. Option 1:  FORMCHECKBOX  The planning committee consists of members of a physician organization that developed this Self-Assessment Program alone or in conjunction with another physician organization. Option 2:  FORMCHECKBOX  The planning committee consists of members of a physician organization that prospectively developed this Self-Assessment Program in conjunction with another non-physician organization. We accept responsibility for the entire program. Date the program was completed:  FORMTEXT        FORMTEXT        FORMTEXT       DD MM YY Has the program been previously accredited? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If the answer to question 4 above was yes, when was the program content and format last reviewed?  FORMTEXT    FORMTEXT        FORMTEXT       DD MM YY The number of hours required to complete the program is  FORMTEXT       hours. Date of the application:  FORMTEXT       Contact Person:  FORMTEXT       Address to send assessment to:  FORMTEXT       Fax Number:  FORMTEXT       Phone Number:  FORMTEXT       E-mail address:  FORMTEXT        Standard 1: Self-Assessment Programs must be developed to address a defined need within a specific subject area, topic or problem. Written Self-Assessment Programs (SAP) must be based on an assessment of need including but not limited to changes to changing or expanding scientific evidence base, established variation in the management or application of knowledge or skills by physicians, variation in the quality of care or health care outcomes experienced by patients. Please provide an explanation and/or supported documentation where required for each of the following: Please describe the identified target audience for this Self-Assessment Program.  FORMTEXT       How was the need for the development of this Self-Assessment Program established?  FORMTEXT       Please describe the learning objectives established for this Self-Assessment Program.  FORMTEXT       Standard 2: Self-Assessment Programs must describe the methods that enable participants to demonstrate or apply knowledge, skills, clinical judgment or attitudes. Self-Assessment Programs provide participants with a strategy to assess their knowledge, skills, clinical judgment and attitudes in comparison to established evidence. All Self-Assessment Programs must use methods that enable participants to demonstrate these abilities across the key areas of the subject area, topic or problem. Please describe the key knowledge areas or themes assessed by this Self-Assessment Program.  FORMTEXT       Please explain the scientific evidence base (clinical practice guideline, meta-analysis or systematic review) selected to develop the Self-Assessment Program.  FORMTEXT       Please describe the rationale for the selected format (for example multiple-choice questions (MCQ), short answer questions (SAQ) or true/false statements) to enable participants to review their current knowledge or skills in relation to current scientific evidence.  FORMTEXT       Standard 3: The Self-Assessment Program must provide detailed feedback to participants on their performance to enable the identification of any areas requiring improvement through the development of a future learning plan. Providing specific feedback on which answers were correct and incorrect with references enables specialists to determine if there are important aspects of their knowledge, skills clinical judgment or attitudes that need to be addressed through engaging in further learning activities. Please describe the process by which participants will provide answers to individual questions. For example through the creation of an answer sheet and scoring key or web based assessment tools. Please provide a copy of the answer sheet or assessment tool  FORMTEXT       Please describe how participants will receive feedback on the answers they provided. Will participants be able to know which answers were answered correctly or incorrectly?  FORMTEXT       Does the program provide participants with references justifying the appropriate answer? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, please describe how the references are provided to participants.  FORMTEXT       Does the program provide participants with an evaluation form that assesses: Relevance of the SAP to the participant s practice? Yes  FORMCHECKBOX  No  FORMCHECKBOX  The thoroughness of the content reviewed? Yes  FORMCHECKBOX  No  FORMCHECKBOX  The ability of the program to assess knowledge? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Please provide a copy of the evaluation form. Does the program direct participants to document their learning in MAINPORT? 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"""$"&"("*","."0"D$F$n$p$r$t$v$x$gd8gdH+Ngd= & F hh^hgd=I$EƀĦa$gd=r$v$$$$$% &!&"&&&&3'@''''''((~(((((((úï~sk_kM_#jh>9$hOJQJUjh>9$OJQJUh>9$OJQJhihDOJQJhihLfOJQJhv6OJQJhihKwOJQJh~0OJQJhih8OJQJhih 1`OJQJh~05OJQJhih85OJQJhC5OJQJhE5OJQJh]5OJQJh$)A5OJQJhih8OJQJ\x$z$|$~$$$!&"&?'@'((((((( **6*8*:*<*>**J+h^hgd^57gd= & F hh^hgd=gd8(((((((() )X))))****$*&*(*2*4*8******+++&+(+D+̶⮜xfxx#jh/hcOJQJUjh/OJQJUh/OJQJhKxOJQJh^57OJQJ#j`h>9$hOJQJUh>9$OJQJhih8OJQJhihDOJQJhihKwOJQJh=hDOJQJjh>9$OJQJU"jh>9$OJQJUmHnHu"D+F+H+J+L+++++++++,, , ,,,,-----:-<->-ûp٨eeûYGY#j4h,h<OJQJUjh,OJQJUhihDOJQJ"jh>9$OJQJUmHnHu#jh>9$hOJQJUh>9$OJQJjh>9$OJQJUhih>9$OJQJhDOJQJh,OJQJhihKwOJQJhih~0OJQJhKwOJQJjh/OJQJU#jJhohuCOJQJUJ+L+++, , ,,,,,l-.j.k.....//// !gdbXh^hgd= & F hh^hgd=gd=>-@-D-F-H-J-f-h-j---------------- . . ...).5.<.=.A.B.C.Q.R.S.T.W.X.Y.ټ}ټk#jh,h<OJQJU#jh,h<OJQJU#jh,h<OJQJUh=OJQJh>9$OJQJhihLfOJQJhihDOJQJ#jh,h<OJQJUjh,OJQJUhKxOJQJhihKwOJQJh,OJQJ*Y.g.h.i.j.k.x............////////"/I/ĹϹڹrd[OFhbX5OJQJh)hbX5OJQJh$)A5OJQJhKxhKw5OJQJ\#jhh,h<OJQJU#jh,h<OJQJUhih>9$OJQJh>9$OJQJhKwOJQJhKxOJQJhihKwOJQJhihLfOJQJhihDOJQJjh,OJQJU#j|h,h<OJQJUh,OJQJI/h/|///////%) YZ[_)*89:?@NOPViopҞ՞֞º¯§¯¯››o§§¯›#jTh,h<OJQJU#jh,h<OJQJUh,OJQJjh,OJQJUhB6OJQJhih6OJQJh OJQJhihLfOJQJhLfOJQJUhbXOJQJh)hbXOJQJhbX5OJQJh)hbX5OJQJ+he ethical standards established for all learning activities included within the Maintenance of Certification program of the Royal College of Physicians and Surgeons of Canada. For example: The developing organization must ensure the validity and scientific objectivity of the content. Each of the following ethical standards must be met for a SAP to be approved under Section 3. The planning committee was in complete control over the selection of the subject or topic and authors recruited to develop this SAP. We comply with this standard: Yes  FORMCHECKBOX  No  FORMCHECKBOX  The planning committee assumed the responsibility for ensuring the scientific validity and objectivity for the content for this SAP. We comply with this standard: Yes  FORMCHECKBOX  No  FORMCHECKBOX  The planning committee and authors will disclose to participants all financial affiliations with any commercial organization(s) regardless of their connection to the subject or topic of the SAP. We comply with this standard: Yes  FORMCHECKBOX  No FORMCHECKBOX  All funds received in support of the development of this SAP were provided in the form of an educational grant. We comply with this standard: Yes  FORMCHECKBOX  No FORMCHECKBOX  Please provide a copy of the budget that identifies each source of revenue and expenditure for the development of this SAP. No drug or product advertisements appear on any of the SAP written materials. We comply with this standard: Yes FORMCHECKBOX  No  FORMCHECKBOX  Please provide a copy of program and any advertisements providing advance notification. Trade names of drugs (where applicable) are used consistently and fairly throughout the SAP written materials. We comply with this standard: Yes  FORMCHECKBOX  No  FORMCHECKBOX  Please identify all organizations that are providing funding for the development of this program.  FORMTEXT       Checklist: Supporting Documentation to be included with this application form: Scoring sheet Yes  FORMCHECKBOX  No  FORMCHECKBOX  Evaluation form Yes  FORMCHECKBOX  No  FORMCHECKBOX  Copy of the budget Yes  FORMCHECKBOX  No  FORMCHECKBOX  Copy of the program Yes  FORMCHECKBOX  No  FORMCHECKBOX  Declaration: I accept responsibility for the accuracy of the information provided in response to the questions listed on this application, and to the best of my knowledge. Applicant Name (physicians name)  Applicant Signature  This section to be completed by the accredited provider This application is Approved  FORMCHECKBOX  Not approved  FORMCHECKBOX  Rationale:!QRמ؞#$23kl_gd6 & Fgd6 & FgdLf & FgdLf  !"(L  !/01lptǠȠ֠נؠڠܠݠϵϪϪ{i#jh,h<OJQJUhihDOJQJ#j,h,h<OJQJU#jh,h<OJQJUhih6OJQJhB6OJQJ#j@h,h<OJQJUhihLfOJQJjh,OJQJU#jh,h<OJQJUh,OJQJ$fijlݡޡ>^_`af͢΢ϢТ˴˴ˬxphh`p˴hyXOJQJhOJQJh OJQJh>9$OJQJh6OJQJ#jhTh<OJQJU#jhTh<OJQJUhTOJQJjhTOJQJUhihDOJQJhih6OJQJhihLfOJQJjh,OJQJU#jh,h<OJQJU#_`ϢТ24\]j  & Fgd6gd6  μᴬִti^SHSh>9$5>*OJQJh]5>*OJQJhihDOJQJhihTOJQJ"jh>9$OJQJUmHnHu#jfh>9$hOJQJUjh>9$OJQJUh^57OJQJh>9$OJQJh6OJQJ#jhTh<OJQJUhTOJQJhih6OJQJjhTOJQJU#jzhTh<OJQJU,.024VXZbdȶȤܜܔȂp^#jhTh<OJQJU#j>hTh<OJQJU#jhTh<OJQJUh$)AOJQJh^57OJQJ#jRhTh<OJQJU#jhTh<OJQJUhTOJQJjhTOJQJUhih1uOJQJhih6OJQJhih65>*OJQJ$ 45CDEFJKYZ[\]hij +,-Ĕ|qgZPZhXCJOJQJhThTCJOJQJh^57CJOJQJhih6OJQJhihD5OJQJhih1u5OJQJhih65OJQJ#j hTh<OJQJU#jhTh<OJQJUhihDOJQJ#j*hTh<OJQJUjhTOJQJUhih1uOJQJhTOJQJ ./fM$$EƀĦIfa$gd<I$EƀĦa$gdT-./01<EGHIJKL]ϧЧѧҧӧߧ˾˾vjbPjEvjhih7OJQJ#j!h&hhh5OJQJUhTOJQJjhTOJQJUhih1uOJQJhih6OJQJh^57OJQJh>9$OJQJh^575OJQJh^575CJOJQJhTh^575CJOJQJhTh^57CJOJQJh^57CJOJQJh6OJQJhT5OJQJhT5CJOJQJhThT5CJOJQJ/012IJRRF $$Ifa$gd|wI$EƀĦa$gd^57bkd $$Ifld064 la|JKLMNOPQRSTUVWXYZ[bkd!$$Ifld064 la|[]ҧӧ02468:<>@BD $Ifgd6 h$If^hgd7 & F$Ifgd6$If $$Ifa$gd6  ",.46:< "68:DŹŧύłpeeŹS#jt#h>9$hOJQJUhih1uOJQJ#j"hTh<OJQJUhih>9$OJQJh6OJQJ"jh>9$OJQJUmHnHu#j"h>9$hOJQJUjh>9$OJQJUh>9$OJQJUhih6OJQJjhTOJQJU#j"hTh<OJQJUhTOJQJ  FORMTEXT       Requires revisions prior to approval  FORMCHECKBOX  Describe the specific areas that require revision:  FORMTEXT            PAGE  PAGE  PAGE 2 DHJLNPRTVXZ\^`bdfhjln$If & F$Ifgd6DFJL\^bdjlnrtxz~躶h 0JmHnHu hThoho ho0Jjho0JUhMCjhMCUhih1uOJQJhih>9$OJQJh>9$OJQJh6OJQJhih6OJQJjh>9$OJQJU)nprvx|~h]hgd$)A &`#$gd5 gkd#$$Ifl,"" t0644 lah]hgd &`#$gdEnh]hgd= 9 0&P1h:p=/ =!"#$% nR`NHhoPNG  IHDR ?HpsRGBgAMA a cHRMz&u0`:pQ< pHYs.#.#x?vIDATx^}=ﷹQ||$>_2ehR/eۦ^ hە!("uO"9c;Hm2s<O_$ Ho??/OB??_ŗ˿|Ð4I@$I@`$?@7M@~-o~C&_1\$9 €0N |bߩXUzԆ0 €0Hw}V?=7ґ:twwSp+Na@x >@~7?iX-RVg?pXA(2w/N 1'TD~a( cW_}%YTQ+b]=h]O'"rxj_a: |DWOȣH1;@6I]q6Vti"2y+6i#WUHGD%Pه $__D0iE*[קH'`fs^0 0jɒF&E"k&R$FWw2FH eg!ͷ'`nLy^Wa@8 %Y(Y7<|29a3dQ;ud2 8MW?3X2a< @Gy2:HN#.GѨr|֞ڿfC](?d\  H: tCp? @ۈJ=3U]Ÿ!}'bUbQLE:7eͣ0d^|v&C__$;N0 yy\Qz>9ܑ 'u)ޑK_W3~p{|nDTXK傾dscGXy2Xf3w /E[:.on L.jB"kk;MgbhؓH%@?@BȆ8/ltyDҫg>#{D!^dw$hdVuExˢYr%;ͫJTɋxd$ 30xW_}HE["1$YHD)fyR<-EK{+JV"p-2l$#o#ɯ$O3H >VImG"D3!z-l`Wb& 6lkd$ €0 <@™:4D?@Fl4LQȚu"#g4 盭wveH~%`6 Whygjܢ?!4V8%"žlxze4N8I /~:H + daHhFdrlG"U;#Hˁ䝳\%'X:O.aDM߽4]X2O"F23"yķ\UL]BKE3"l꣧ߞ{{s@zU};r#ۡ߅a@T <@D G U >@F7:G*fVA J`^b;Y,xH(@yبN׮@27 h3QxUDQ72vIrRa@GȣI^Ez&29M[іU0EXdf'DzneTM 3w&t/+(lGoä?; $s mȗ%~K_w5ta&kA6se\v3iGeH €0 <# @F$5"y,y#:"" ц֙%Ͷ=/e&;\j@ R?ɋf@0ӓ^ \oZcRMЫ €0 Tc6TQ6md_WN\5*;@‘cly)AE>@20#OlbD6(Ep1OTϊZ 2"㿣!X22"ϬN;f2XڢJ €0 \[3k%x;QRD0TmI ?o|U;YY`J_Y:l"J+Dzg&rȕE$32|ʶ3ڒ3) 2}q^N gil$IE 阺:3t A マgZqxGz",63N7Ȏ׆cc0D*^2wب$2# KqؕY].g_5 T;>gʮ,a˱7b|lqJ_~ CNv}8 ޲Nc;O"1H>{2RNZ+2FH ٨s \%qfd gF+tgpΝrB(͗G*8Jn0 2*K ~DWYD2CVofeo~s@ȫ=\:khgʖL~ Ft%t YM?b6ׇz>gZqƱo"Q~ga0>kY8LgjYDcǭd+ <"2ɤ΢|Ks6ݬ ózq~H00Kon.$«0^ϗH6'Ks`D69 #QEԒ1Bd"L?T$HWc`Fˊf}}ƶaǀx@o6z,69R\tA,TI:x 22i"o, "t!\LTJe~hހ%0֛z7A>0 <@f\:F A1R!ZzЂ"<ev ,ySO0, "TcIU@<#HشYDO^?YDJceGaWKa1 yO# X+g m`L23)!t$|{fGg&S8̙~V} Gz`NEt|#. 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