MetroHealth Medical Center
CME Conference Application
Questions or concerns?
Please contact Steven Ostrolencki at 216-778-1175 or Carrie Henceroth at 216-396-1136.

Please Note: This form must be completed in one session. You will be asked to upload and attach the following documents:
     •  Complete Program Schedule (Including: dates, times, topics, and speakers.)
     •  Faculty Disclosure Form [PDF] (This must be completed by all activity planners, faculty/presenters,
         and staff participating in this activity.)
     •  Sources of information used to identify practice gap.
     •  If the CME activity will receive commercial support, Written Agreement for Commercial Support [PDF].

CME Activity Director / MetroHealth Faculty Member

Meeting Planner/Staff Coordinator #1

Meeting Planner/Staff Coordinator #2

Activity Information

New or Repeat Activity? *

Activity Dates and Location

Program Schedule

I will submit at a later date. *

Faculty/Planning Committee

Please provide a complete list of faculty/presenters, course director(s), and planning committee; including title and affiliation. Note: Each committee member must sign a disclosure form [PDF] .

At least three planners are required. Click the PLUS sign to add rows.

Estimated Attendance # and Target Audience

Target Audience including specialties (required in all promotional and syllabus materials). Select all that apply: *

Practice Gap

Please indicate the educational need(s) that this activity addresses. Select all that apply: *

Needs Assessment

What source of information did you use to identify your practice gap? Select all that apply: *

Core Competencies

CME activities should address core competencies as determined by national or specialty society, specialty credentialing boards, or other sources of national priority. Please indicate the competency and/or other desirable physician attributes that would be used/address in the development of this activity. 

Select all that apply:
Accreditation Council for Graduate Medical Education (ACGME) / American Board of Medical Specialties (ABMS) *
Institute of Medicine (IOM) *


Based on the need/professional practice gap identified, what are the learning objectives of this activity? These objectives should be measureable and include the increased competence and/or improved performance and/or improved patient outcome that you wish to address in this activity. Please use How to Prepare Educational Objectives [PDF] to formulate.
At the end of this CME activity, participants should be able to:
(3 answers are required. Click the PLUS sign to add rows) *
Please indicate how these objectives will be communicated. Select all that apply: *


Considering the setting, objectives and desired results, what format(s) will you use to promote the changes identified in your objectives? Select all that apply: *
Please indicate the instructional methods that you tend to use. Select all that apply: *
Is the format appropriate for the activities’ setting, objectives and desired outcomes? *


CME activities should give consideration to the system of care in which the learner will incorporate new or validate existing learned behaviors. What potential barriers do you anticipate the learner may encounter when trying to make the changes this activity is designed to promote? Select all that apply: *

Non-Educational Strategies

In the process of planning this activity, what non-educational strategies will you utilize to enhance the changes this activity is promoting? Select all that apply: *

Evaluation and Outcomes

The MetroHealth CME mission and the Ohio State Medical Association (OSMA) require that every CME activity be designed to change physician competence, and/or performance, and/or patient outcomes. 
Which of the following outcomes is the activity designed to facilitate? Note: Follow-up reports/data will be required for each item selected below. Select all that apply: *
How will you measure if changes in Competence, Performance or Patient Outcomes have occurred? Select all that apply: *

Commercial Support

Will the CME activity receive commercial support from a pharmaceutical, medical device company or other commercial entity? Support includes financial and in-kind grants or donations. Exhibit fees are NOT considered education program commercial support. View our Commercial Support Policy [PDF]. *
If yes, please review the ACCME Standards for Commercial Support. Do you agree to abide by them?


Will speaker(s) receive an honorarium and/or reimbursement? *
If yes, payments must be made in compliance with the MetroHealth CME office’s written
Policy on Honoraria and Reimbursement [PDF] as well as the ACCME Standards for Commercial Support.
If yes, what is the source of payment? For Jointly Provided activities, payments must be made in compliance with MetroHealth CME office’s written Jointly Provided Policy on Honoraria [PDF] as well as the ACCME Standards for Commercial Support.

Course Director Signature (MetroHealth Faculty Member)

Note: By submitting this form, you agree your electronic signature is the equivalent of your written signature. 
Electronic Signature *

Conflict of Interest/Disclosure

All activity planners, faculty/presenters and staff participating in this activity must complete a Faculty Disclosure Form [PDF]. Disclosure forms must be updated every 12 months.
Email if you have any questions.

CME Credit will not be awarded for this activity until all disclosure forms are received and reviewed. All completed forms must be sent to the CME Office at the email address below:
          Fax: 216-778-5862

Letters of Agreement for Commercial Support

Letters of Agreement are required for all commercial support.
All Letters of Agreement (LOAs) for educational grants must be completed and signed by a MetroHealth CME Specialist (accredited provider) and the commercial supporter (exhibitors exempt) and then returned to Steven Ostrolencki in the CME Department prior to the start of the activity. Letters can be scanned to expedite approval and signatures.

Written Agreement for Commercial Support [PDF] 
All disclosures must be sent to prior to application being reviewed for approval.