Forms (for applications or renewals)

Sample forms and templates to support your application can be found below. These documents should be uploaded to your application in eCME as an attachment.

Verb List
Flyer / Brochure
Brochure Guidelines (for reference)
Evaluation Instrument
Disclosure Form (Updated 07/2018)
Conflict of Interest (COI) Resolution Letter (template)
Commercial Support Letter (template)
Joint Provider Letter (template)

Need help with the budget?
The sample budget form can be used as a guide to help you determine costs that should be reported for a CME activity. Please be sure to consult with the CME Coordinator about the budget for your activity before you submit the proposal.
Note: The sample budget should just be used as a guide to determining your budget. The formal budget should be entered into eCME under the “Budget Details” tab. Please do not upload the sample budget to eCME.

Post Activity Forms

After a CME activity takes place, a post activity report must be submitted along with all required supporting documentation.  Certificates are distributed only upon successful submission and acceptance of the post activity report. Please see the forms/templates below.

Post-Activity Table
Attendance Tracker

Commercial Support and Financial Disclosures

Note that all CME activities receiving financial support from a commercial entity are required to submit a commercial support letter.  In addition, the following documentation must be submitted to the eCME system by the post-activity reporting is conducted:

  • All written executed agreements between the activity provider and the commercial support entity.  These agreements must be signed by both parties.

For financial disclosures, all persons in control of CME content including, Activity Directors, Planning Committee members, and speakers must disclose and sign a financial disclosure regardless of a relevant interest or not.  For those persons with relevant financial disclosures, a Conflict of Interest Resolution Letter must be provided by either the Activity Director or Department Chair, which states that the person’s disclosed financial relationship does not conflict with the person’s activity role or learning content.  In the event that an Activity Director has a relevant financial disclosure, the providing department should identify a person (e.g. Department Chair) who does not have a relevant financial disclosure and provide a signed Conflict of Interest Resolution Letter for all persons in control of content for the activity.  If a conflict does exist, the provider may designate a different activity director who does not have a relevant financial disclosure and whom must ensure the learning content does not conflict with any previous disclosed financial relationships.

In addition, all persons in control of content for an activity must disclose all  or no relevant financial relationships to activity attendees at the start of the activity or, for speakers, at the beginning of their session.  These disclosures may be made verbally, by hand-out, or via a presentation slide.  For disclosures made verbally, a transcribed document of the verbal disclosure(s) must be submitted to the eCME system upon completion of the post-activity reporting.  All other records of relevant financial disclosure made via hand-out or presentation slide must be collected and submitted to the eCME system by completion of the post-activity reporting.