List all other planning/scientific committee members and their affiliation and expertise brought to the committee: Committee Member Expertise Affiliation Queen’s Faculty? Is the planning committee accountable to the head of the department, chief of staff or equivalent? Yes, describe how and to whom accountability is measured for the planning committee: (Box expands as needed) No Will /has the planning committee members demonstrated substantial input by: Yes No Determining selection of all topics Yes No Determining program content Yes No Writing learning objectives Yes No Selecting all speakers/presenters Yes No Ensuring disclosure slides are presented Yes No Reviewing conflicts of interest disclosures and adhering to a plan to mitigate potential biases Yes No Reviewing evaluations Reviewing all presentation materials to: Yes No 1) determine content is evidence based Yes No 2)Medication is referred to by the generic name (tradenames can only be listed if all trade names are included) Yes No 3) Slides / Materials do not follow the corporate colours of any relevant pharmaceutical company or product Yes No Ensuring speakers and program adhere to the Yes No Ensuring speakers and program adhere to the Who is the target audience for this program (select all that apply) Academic Family Family Physicians with a community of practice in: Physicians Addiction Medicine Health Care of the Elderly Interprofessional teams Cancer Care Hospital Medicine Researchers Child and Adolescent Health Maternity and Newborn Care Residents Chronic Pain Mental Health & Remote practicing Dermatology Occupational Medicine Family Physicians Developmental Disabilities Palliative Care Urban practicing Family Emergency Medicine Prison Health Physicians Family Practice Anesthesia physicians Respiratory Medicine Global Health Sport and Exercise Medicine Identify the / roles addressed in this program: Collaborator Communicator Family Medicine Expert / Medical Expert Health Advocate Leader Scholar Professional The program evaluation must include the following questions. Please confirm these have been included: This program enhanced my knowledge (Strongly Agree Disagree) ….Neutral…Strongly
List all other planning/scientific committee members and their affiliation and expertise brought to the committee: Committee Member Expertise Affiliation Queen’s Faculty? Is the planning committee accountable to the head of the department, chief of staff or equivalent? Yes, describe how and to whom accountability is measured for the planning committee: (Box expands as needed) No Will /has the planning committee members demonstrated substantial input by: Yes No Determining selection of all topics Yes No Determining program content Yes No Writing learning objectives Yes No Selecting all speakers/presenters Yes No Ensuring disclosure slides are presented Yes No Reviewing conflicts of interest disclosures and adhering to a plan to mitigate potential biases Yes No Reviewing evaluations Reviewing all presentation materials to: Yes No 1) determine content is evidence based Yes No 2)Medication is referred to by the generic name (tradenames can only be listed if all trade names are included) Yes No 3) Slides / Materials do not follow the corporate colours of any relevant pharmaceutical company or product Yes No Ensuring speakers and program adhere to the Yes No Ensuring speakers and program adhere to the Who is the target audience for this program (select all that apply) Academic Family Physicians Interprofessional teams Researchers Residents & Remote practicing Family Physicians Urban practicing Family Physicians Family Physicians with a community of practice in: Addiction Medicine Cancer Care Child and Adolescent Health Chronic Pain Dermatology Developmental Disabilities Emergency Medicine Family Practice Anesthesia physicians Global Health Health Care of the Elderly Hospital Medicine Maternity and Newborn Care Mental Health Occupational Medicine Palliative Care Prison Health Respiratory Medicine Sport and Exercise Medicine Identify the / roles addressed in this program: Collaborator Communicator Family Medicine Expert / Medical Expert Health Advocate Leader Scholar Professional The program evaluation must include the following questions. Please confirm these have been included: This program enhanced my knowledge (Strongly Agree ….Neutral…Strongly Disagree)
1_CertificationAccreditationApplication_CFPC%20Updated.docx