Faculty Agreement - Joint Providership

Contact Information

Contact information provided will appear in promotional materials.

Name(Required)

First Last

Credential(Required)

R. Ph.

Pharm. D.

B.S. Pharm.

CPhT

Other:

Credential other:

Title(Required)

Organization(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Email Address(Required)

Activity Details

Please provide details of the activity

Activity Title:(Required)

Event Name (if different):

Activity Variant(Required)

LIVE ACTIVITY INFORMATION

Date(Required)

Time(Required)

Length of Lecture(Required)

Facility(Required)

Curriculum Vitaé and Biography(Required)

Submit a detailed CV via e-mail and write a short biography below for inclusion in the onsite faculty introduction. Bio should be no longer than 250 words.

Educational Needs Asessment and Gaps in Knowledge

Faculty, along with the organization hosting the continuing education activity, should identify the problem or clarify the need (gaps in knowledge), the current state of pharmacy practice and the desired state of pharmacy practice. This should be evidence-based facts, rather than assumptions, and should be used to formulate what should be learned in order to move the learners from their current state of practice to the desired state and assist in developing learning objectives. References and citations should be provided where appropriate.

Develop and Clarify the Need(Required)

What is the problem (potential or actual) that needs to be addressed? Or, what new process or procedure (current or future), recent change or expected changes are happening that will affect this group?

Current State of Practice(Required)

What is the audience doing now that could or has led to this problem based on facts, rather than assumptions? Provide references or citations. Or, where is the audience currently in this skill, training, process or procedural aspect?

Desired State of Practice(Required)

What should or could the audience be doing instead to solve or prevent this problem? Or, what information, skill or technique will the audience need to attain in order to implement this new process or procedure?

Learning Objectives

Michigan Pharmacists Association (MPA) will attempt to accredit your program for pharmacists and pharmacy technicians by following the ACPE accreditation standards. Programs that benefit pharmacists and pharmacy technicians must have specific and separate learning objectives for each audience. If your pharmacy continuing education activity (PCE) benefits only pharmacists, only pharmacy technicians or both, please complete the appropriate learning objective section below. See pages 24-25 for guidelines on how to develop specific and measurable learning objectives. MPA must approve learning objectives.

This PCE activity will include discussion of off label use.(Required)

Yes

Not Sure

Targeted Audience(Required)

Pharmacists

Pharmacy Technicians

Students

Pharmacist Learning Objectives

A minimum of three objectives are required. The majority of the objectives should be structured to meet identified educational gaps in knowledge that will move learners to a desired state of practice.

At the end of this activity, participants should be able to:

*Select an ACPE approved verb from the drop down menu

1. Pharmacist Learning Verb(Required)

1. Pharmacist Learning Detail(Required)

2. Pharmacist Learning Verb(Required)

2. Pharmacist Learning Detail(Required)

3. Pharmacist Learning Verb(Required)

3. Pharmacist Learning Detail(Required)

4. Pharmacist Learning Verb

4. Pharmacist Learning Detail

5. Pharmacist Learning Verb

5. Pharmacist Learning Detail

Pharmacy Technician Learning Objectives

*Select an ACPE approved verb from the drop down menu

1. Pharmacy Technician Learning Verb(Required)

1. Pharmacy Technician Learning Detail(Required)

2. Pharmacy Technician Learning Verb(Required)

2. Pharmacy Technician Learning Detail(Required)

3. Pharmacy Technician Learning Verb(Required)

3. Pharmacy Technician Learning Detail(Required)

4. Pharmacy Technician Learning Verb

4. Pharmacy Technician Learning Detail

5. Pharmacy Technician Learning Verb

5. Pharmacy Technician Learning Detail

Program should be accredited for the indicated Topic Designator (select one):(Required)

01: Disease State Management/Drug Therapy - activities that address drugs, drug therapy, and/or disease states

02: HIV/AIDS - activities that address therapeutic, legal, social, ethical, or psychological issues related to the understanding and treatment of patients with HIV/AIDS.

03: Law Related to Pharmacy Practice - activities that address federal, state, or local laws and/or regulations affecting the practice of pharmacy.

04: Pharmacy Administration - activities that address topics relevant to the practice of pharmacy that include the economic, legal, social, administrative, and managerial aspects of pharmacy practice and health care.

05: Patient Safety - activities that address topics relevant to the prevention of healthcare errors and the elimination or mitigation of patient injury caused by healthcare errors.

06: Immunizations - activities related to the provision of immunizations, i.e., recommend immunization schedules, administration procedures, proper storage and disposal, and record keeping. This also includes review for appropriateness or contraindication and identifying and reporting adverse drug events and providing necessary first aid.

07: Compounding - activities related to sterile, nonsterile, and hazardous drug compounding for humans and animals. This includes best practices and USP quality assurance standards, environmental testing and control, record keeping, error detection and reporting, and continuous quality improvement processes.

08: Pain Management - activities that address any component regarding the treatment and management of pain, including the prescribing, distribution and use of opioid medications, and/or the risks, symptoms, and treatment of opioid misuse/addiction.

Activity Type(Required)

Knowledge-based Activity
These activities primarily transmit knowledge (i.e., facts). The facts must be based on evidence as accepted in the literature by the health care professions.

Learning Assessment – Each activity in this category must include a multiple-choice posttest.
Assessment Feedback – The organization hosting the continuing education activity or Michigan Pharmacists Association will provide participants with answers to posttest questions, along with an explanation of why the correct answers are the most appropriate.

Application-based Activity
These activities are primarily constructed to apply the information learned in the time frame allotted. The information must be based on evidence as accepted in the literature by the health care professions.

Learning Assessment – Each activity in this category must include case studies structured to address application of the principles learned, or another hands-on approach.
Assessment Feedback – Feedback should be provided by faculty during delivery of the activity and include the correct evaluation of case studies and rationale for correct responses.

Licensing Requirements(Required)

Does this CE fit a Michigan licensing requirement?

Yes

If yes, please select which requirements this CE fits:(Required)

Controlled Substance

Human Trafficking

Implicit Bias

Jurisprudence and Ethics

Pain

Patient Safety

Other

Activity Materials

Handout In an effort to enhance the participant’s knowledge of this topic, you are required to develop and submit a handout, such as PowerPoint® slides, and an outline, references or key points (limited to one page). See page 27 for guidelines to assist you in developing appropriate handouts or visual aids. An outline, references and key points example is located on page 28. Your handout and outline, references or key points are due 20 days prior to the presentation. Educational materials that are part of the PCE activity, such as slides, abstracts and handouts, cannot contain any advertising, corporate logo, trade name or a product-group message of an ACPE-defined commercial interest.

Posttest To evaluate the level of competency attained during knowledge-based activities, a posttest will be provided to participants. Faculty should submit questions in the multiple-choice format and include only four possible answer choices (unless true/false, in which case, only two choices are needed). Posttest questions should be directly related to the learning objectives. See below for the required number of questions, based on how long the activity is. Faculty should also provide feedback after each question explaining why the chosen answer is correct. Below is an example. A posttest is not required for application-based activities. Posttest questions, answers and feedback must be submitted no later than 20 days before the activity.

Hours Per Activity	Required Number of Q&A
1-1.75	4
2 to 3.75	8
4 to 5.75	12
6 to 7.75	16
8 to 9.75	20

Example Posttest Question with Correct Answer and Feedback: To have a positive CAM-ICU, patients must have all four delirium characteristics: acute onset and fluctuating course, inattention, disorganized thinking and altered level of consciousness. a. True b. False

Feedback: Answer B is the most appropriate response because patients must have three out of four characteristics. To have a positive CAM-ICU screen, patients must have acute onset and fluctuating course, evidence of inattention and either signs of disorganized thinking OR altered level of consciousness.

Case Studies: For application-based activities, case studies must be submitted no later than 20 days before the activity.

Sponsorship

In accordance with the commercialism policy, no funds can go directly from the commercial supporter to the speaker; therefore, the organization hosting the continuing education activity and/or MPA will not be held responsible for signing grant requests or funding applications of any kind should you seek funding on your own.

Disclosure

Accredited activities shall exhibit fair content balance, providing the audience with information of different perspectives from which to develop an informed professional opinion. All relevant financial relationships with anyone who is in a position to control the content, including commercial interest and spouses/partners must be disclosed. In addition, should it be determined that a conflict of interest exist as a result of a financial relationship you may have, this will need to be resolved prior to the activity. This information is necessary in order for us to be able to move to the next steps in planning this activity. If you refuse to disclose relevant financial relationships, you will be disqualified from being a part of the planning and implementation of this activity.

First, list the names of proprietary entities producing health care goods or services, consumed by, or used on patients, with the exemption of nonprofit or government organizations and non-health care-related companies with which you or your spouse/partner have, or have had, a relevant financial relationship in any amount within the past 24 months that create a conflict of interest. Second, describe what you received (ex: salary, honorarium, etc.) You do not need to reveal how much you received. Third, describe your role.

Disclosure Statement(Required)

I have a relevant financial relationship with any commercial interests, or I have a relationship with anyone who influenced content of this activity.

I do NOT have any relevant financial relationship with any commercial interests, nor do I have a relationship with anyone who influenced content of this activity.

Nature of Relevant Financial relationship(Required)

Commercial Interest and Influential Relationship | Example: Company “X” or name of person(s) other than yourself controlling content

What I received | Example: Honorarium

My Role | Example: Speaker

What was received: Salary, royalty, intellectual property rights, consulting fee, honorarium, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.

My role(s): Employment, management position, independent contractor(including contracted research), consulting, speaking and teaching, membership on advisory Committees or review panels, Board membership and other activities.

Compensation

Faculty shall be compensated by HOSTING ORGANIZATION in the following manner. You are responsible for making your own travel including mileage, unless otherwise noted.

Honorarium

Honorarium Checkboxes

Expense

Expense Checkboxes

Additional Compensation

Additional Compensation Checkboxes

Indemnification

Faculty will indemnify Hosting Organization and Michigan Pharmacists Association (MPA) from and against all claims, including, but not limited to intellectual property infringement, copyright, damages, liabilities, expenses and judgments recovered from or asserted against Hosting Organization and/or MPA as a result of faculty presentation, materials and activities under this Agreement. Hosting Organization and MPA agrees to indemnify faculty from and against all claims, damages, liabilities, expenses and judgments recovered from or asserted against faculty as a result of participation in Hosting Organization’s educational program accredited through MPA and based on willful, wanton or negligent conduct on the part of the Hosting Organization and/or MPA. Intellectual property includes photos, images, media and video.

I, hereby, confirm all information as set forth above, as true and correct, and agree to deliver the activity as I have stated above in both a professional and educational matter. I also acknowledge and accept the compensation as outlined above as payment in full for my services. MPA reserves the right to withhold reimbursement should an activity lend itself to a biased nature. Changes or alterations to this agreement are not valid unless initialed by both parties.

I further warrant and represent that this activity is my own original work, that I have the authority to enter into this agreement and that I am the sole copyright holder, or that I have obtained all necessary permissions or licenses from any persons or organizations whose material is included or used in my presentation.

Faculty Signature(Required)

Print Name(Required)