Dear Applicant for Joint Sponsorship:

Dear Applicant for Joint Sponsorship: In preparing an application for a CME activity, it is imperative that the applicant follow the Accreditation Review Committee of the Oklahoma State Medical Association requirements. TCMS is accredited by the OSMA to provide continuing medical education for physicians and periodically TCMS is surveyed by the OSMA to assess the performance in practice of TCMS with respect to the planning and presentation of CME activities. As you prepare your application please keep in mind that in order for TCMS to maintain its OSMA accreditation, your activity file must meet the requirements listed below: THE DOCUMENTATION FOR ALL ACTIVITIES MUST SHOW THAT: A planning process was used that linked the identified educational needs and learning gaps of the target audience with a desired result. An educational need is a gap between what is (current practice) and what could be (best practice). Multiple needs assessment data were used to plan the activity (required minimum of 2). The purpose/objectives of the activity were communicated to the learner prior to the activity through an announcement. The activity was evaluated in terms of the effectiveness in meeting the identified needs and learning gaps. All printed materials for the activity carry the appropriate accreditation statement for AMA PRA Category 1 Credit(s). All faculty or planner relationships were disclosed and made known to the participants. All the recommendations involving clinical medicine in a CME activity are based on best evidence accepted within the profession of medicine (as adequate justification for their use to improve the care of patients). Signed agreement(s) between the provider and commercial supporter(s) are present. Faculty and planner relationships with commercial supporters were disclosed to learners via 1) announcement at the beginning of the meeting, 2) printed on the meeting notice, 3) a copy placed on each participant table, 4) printed on the evaluation form or copied on the back of the evaluation form, or 5) displayed on the screen at the beginning of the meeting. Acknowledgement of commercial support occurred. All conflicts of interest have been identified, reported to and resolved by TCMS and the Joint Sponsor and communicated to the audience. The TCMS honoraria policy (attached) is adhered to. No product-promotion or product specific advertisements are juxtaposed with educational materials or sessions. A complete application must contain: 1. Application form 2. Multiple support documentation verifying needs and learning gaps 3. CV s from the speakers 4. Completed disclosure forms from planning committee members and speakers 5. Commercial Support information 6. Proposed budget 7. Brochure/flyer/announcement draft See attached checklist

The following checklist will be helpful to you in meeting all the requirements needed in order for us to jointly sponsor your CME activity. Information provided to TCMS with application: Application Developed needs assessment Program Content/Objectives Projected budget of program Curriculum vitae for each speaker Honorarium amounts for each speaker (if applicable) Application completed and submitted (date) Following approval of your program please submit the following to TCMS: Accreditation Fee Paid to TCMS (date) Brochure information Draft of brochure for approval Please do not distribute brochure until it is approved Accreditation statements printed in specifics with number of hours listed Target audience Objectives listed on brochure Speaker information included Commercial Support TCMS Joint Sponsor Letter of Agreement Copy of letter of agreement from sponsoring company (commercial supporter) Documentation and acknowledgement of support to participants Documentation of speaker/faculty disclosure regarding commercial support *Speaker(s) Disclosure statements signed by each speaker/faculty and any conflicts were resolved. Disclosure statements signed by each individual organizing the program and any conflicts were resolved. Documentation of speaker/faculty disclosure (and any conflicts if applicable) to participants. Copy of Handouts *Speakers should be chosen soley for their ability to work within the methods of instruction chosen to help participants in achieving the learning objectives. Speaker disclosure must be made to the audience of any real or apparent conflict of interest with the content of their presentations, the overall subject matter of the activity, and/or if they are on the speaker s bureau of any company.

After your program please forward the following documentation to TCMS. Final budget of all program expenses and income. Evaluation of program (provide summary to TCMS) Sign in sheet provided to TCMS must include name, title, address and contact information that is legible. Documentation as to how disclosure was made to the audience (verbal announcement copied on back of evaluation, included in publicity, displayed on participant tables on back of evaluation, included in publicity, displayed on participant tables, slide at beginning of program. A copy of this checklist (or the RSC checklist if the program is a regularly scheduled conference.

TULSA COUNTY 5315 S Lewis Avenue Web site: www.tcmsok.org MEDICAL Tulsa, Oklahoma 74105-6539 email: tcms@tcmsok.org SOCIETY (918) 743-6184 fax: (918) 743-0336 APPLICATION FOR JOINT SPONSORSHIP Please submit this application at least sixty days prior to the program date. Tulsa County Medical Society is accredited by the Oklahoma State Medical Association to provide continuing medical education. To fulfill requirements of the OSMA the completion of this application is necessary to be eligible for joint sponsorship. The accreditation fee for a program 1-4 hours is $1000.00 and for a program 5-8 hours is $1500.00. The fee for RSS is $500.00 per session. Please include the C.V. (curriculum vitae) of all faculty involved in the program presentation. Organization Name Address Contact Name Email Phone Number Fax Program Title Program Date Time Location Anticipated Audience % Physicians % Other Allied Health Professionals Specific Target Audience Council/Committee/Department The following sections must be completed for Category 1 credit: Educational Needs and Learning Gaps Addressed by this Activity: What are the problems/needs/gaps of the target audience that this activity will address? (Summarize why this activity is needed.) For medical conditions and practice activities relevant to this target audience, the target audience needs: Patient Care Diagnosis Treatment review of established methods review of established methods information on new methods information on new methods new or improved skills new or improved skills Medical Knowledge Advancement review of knowledge base generally recognized as current and applicable. information on new findings in basic or clinical sciences information on how to perform medically related research new or improved skills in performing medical related research Practice Based Learning and Improvement information on the extent to which recommended care is not being provided information on how to evaluate scientific evidence and or improve personal practice new or improved skills to evaluate scientific evidence and or improve personal practice 19

Interpersonal and Communication Skills information on methods to improve interpersonal relationships and communication new or improved interpersonal and communication skills Professionalism information on medical ethics, professional responsibilities, medico legal issues and/or sensitivity to a diverse patient population. new or improved skills regarding medical ethics, professional responsibilities, medio legal issues and/or sensitivity to a diverse patient population. Systems-Based Practice information on practice management new or improved management/administrative skills information on multi-specialty/multidisciplinary coordination of care Other (Summary Required) How were Needs Determined (Documentation is required) What information and/or data did you use to determine the need/gaps for this program by your target audience? To show how needs were determined you must enclose documentation). This application will not be considered if at least two needs sources are not used and if data sources are not attached. (check all that apply). Patient care audit Physician Survey Review/update New technique/material Quality Assurance Epidemiological Data Search of current literature Evaluations of previous programs Planning Committee minutes Advice from authorities in the field National and/or regional and/or state health statistic data Other Objectives The learning objectives must be listed in all promotional materials including brochures, syllabus, flyers, website listings, and on announcements. You must use action verbs that are measureable like (name, identify, explain, describe, compare, perform). List objectives below Upon completion of this activity, the participant should be able to: (may attach if easier) 1. 2. 3. Evaluation Form TCMS will prepare evaluation forms for your program and send you enough copies for your registered participants prior to the meeting. The participant will keep the yellow copy of the evaluation form as evidence of their participation in the meeting. Results and Outcomes What results or outcomes are expected from providing this activity (check all that apply) Patient Care increased knowledge of diagnostic methods improved diagnostic skills increased knowledge of treatment methods improved treatment skills Medical Knowledge Improvement review of knowledge base generally recognized as current increased knowledge of new findings in basic/clinical sciences increased knowledge of how to perform medically related research improved skills in performing medically related research Practice Based Learning and Improvement increased knowledge on how to evaluate scientific evidence and or improve personal practice improved skills to evaluate scientific evidence and/or improve personal practice Interpersonal and Communication Skills increased knowledge of methods to improve interpersonal relationships and communication improved interpersonal and communication skills 20

Professionalism increased knowledge of medical ethics, professional responsibilities, medico legal issues and/or sensitivity to a diverse patient population. improved skills regarding medical ethics, professional responsibilities, medico legal issues and/or sensitivity to a diverse patient population. Systems-Based Practice Increased knowledge about practice management Improved management/administrative skills Increased knowledge about multi-specialty/multidisciplinary coordination of care Other Will you have Commercial Support for your activity? Yes No Policy for Commercial Support. If yes, please follow the guidelines in the attached Budget Information: Attach a copy of proposed budget (include speaker honorarium if any and all other expenses) * Must be included on the brochure/flyer along with the accreditation statement. Brochure/Flyer must be approved by TCMS. Date Submitted Signature Approved Not Approved Comments: 21

TULSA COUNTY MEDICAL SOCIETY CONTINUING MEDICAL EDUCATION POLICY AND PROCEDURE MANUAL SUBJECT: POLICY FOR JOINT SPONSORSHIP DATE: DECEMBER 1, 2004, REVISED 8/25/05, REVISED 8/30/06, REVISED 12/3/09 Tulsa County Medical Society has adopted the OSMA Policy for Joint Sponsorship, which is as follows: The Accredited sponsor shall accept responsibility that the essential areas are met when educational activities are planned and presented in joint sponsorship with non-accredited sponsors. The sponsor shall be able to: 1. Show with written documentation that each sponsored CME activity was planned and implemented in compliance with the Essentials of OSMA. 2. Carry the following statement on all printed materials for activities created according to the Essentials: This activity has been planned and implemented in accordance with the Essentials and Policies of the Oklahoma State Medical Association through the joint sponsorship of the Tulsa County Medical Society (TCMS) and the (non-accredited provider name). TCMS is accredited by the Oklahoma State Medical Association (OSMA) to provide continuing medical education for physicians. TCMS designates this * activity for a maximum of AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity. * type of AMA approved learning format must be listed, 1) live activity, 2) enduring material, 3) journal based CME activity, 4) test-item writing activity, 5) manuscript review activity, 6) PI CME activity, 7) internet point-of-care activity. 3. Tulsa County Medical Society will utilize specific written policies and operating procedures to effectively govern the planning and implementation of its jointly sponsored activities. Tulsa County Medical Society may require that the non-accredited sponsor meet requirements that are more restrictive than or exceed the minimum requirements of the OSMA. EXPLANATION AND RATIONALE Tulsa County Medical Society may be asked by organizations, which are not accredited to jointly sponsor CME activities, since TCMS is an accredited sponsor. When TCMS agrees to joint sponsorship we will accept responsibility that the Essentials and OSMA Policies are met. GUIDELINES The Policies require that a sponsor must accept responsibility that all requirements are met for CME activities it jointly sponsors with non-accredited organizations. TCMS will provide information on these jointly sponsored activities when resurveyed for accreditation and will demonstrate that we have participated integrally in the planning and implementation of these activities. Jointly sponsored activities must be consistent with the sponsors mission statement. The sponsor must conduct an evaluation of each jointly sponsored CME activity. The name of the accredited sponsor should appear on all promotional materials and on the printed program of the jointly sponsored activity. Some local chapters or affiliates of national organizations are neither independently accredited nor specifically included in the accreditation of the national organization. The 16

accredited national organization should take care that it is not listed as the joint sponsor of CME activities of such local chapters or affiliates unless the requirements of this Policy are met. The requirements for a jointly sponsored Category 1 program are the same as for any other Category 1 program. The answer to all the following questions should be yes. (1) Does it meet the definition of a planned program of CME?..a planned program of CME is defined as one that covers a need(s). (2) Is the program designed with the specific needs of physicians in mind? (3) Has a needs assessment been conducted? (4) Have educational goals and objectives been formulated? (5) Are suitable facilities available? (6) Does the format and a faculty serve the educational goals and objectives? (7) Will an objective evaluation be carried out and used in planning subsequent programs? (8) Have the financial arrangements and any conflict of interest been managed in accordance with the Standards for Commercial Support? What responsibilities does Tulsa County Medical Society have to OSMA? An account of joint sponsorship activities should be included in the annual report submitted to the OSMA Council on Medical Education. This area will also be reviewed at the time of re-survey site visits. When TCMS joint sponsors a program the organization presenting the program will serve as the Course Director and will be responsible for: Administration: Evaluation Form & Summary Commercial Support Letter of Agreement LOA documentation Disclosure of commercial support & speaker disclosure declarations to participants. Registration: Publicity: Financial Support: Pre-Course Registration Name Tags Weekly/Monthly Enrollment Reports On-site registration book/instructions/receipt book Production of the announcement, flyer or brochure Preliminary Budget and Final Reporting Speaker Travel/Honoraria Processing without commercial support Speaker Travel/Honoraria Processing with commercial support Organization directly reimburses other expenses with or without commercial support Closing the File: Subsequent to the meeting the organization will furnish a complete file to TCMS that will include: List of attendees with name, address and contact information that is legible. Copies of the sign-in/registration form Copies of the CME certificates Summary of the evaluation forms 17

Does it meet the definition of a planned program of CME? A planned program of CME is defined as one that covers a need(s). (1) Is the program designed with the specific needs of physicians in mind? (2) Has a needs assessment been conducted? (3) Have educational goals and objectives been formulated? (4) Are suitable facilities available? (5) Does the format and faculty serve the educational goals and objectives? (6) Will an objective evaluation be carried out and used in planning subsequent programs? (7) Have the financial arrangements and any conflict of interest been managed in accordance with the Standards for Commercial Support? What responsibilities does Tulsa County Medical Society have to OSMA? An account of joint sponsorship activities should be included in the annual report submitted to the OSMA Council on Medical Education. This area will also be reviewed at the time of re-survey site visits. When TCMS joint sponsors a program the organization presenting the program will serve as the Course Director and will be responsible for: Administration: Evaluation Form & Summary Commercial Support Letter of Agreement LOA documentation Disclosure of commercial support & speaker disclosure declarations to participants. Registration: Publicity: Financial Support: Pre-Course Registration Name Tags Weekly/Monthly Enrollment Reports On-site registration book/instructions/receipt book Production of the announcement, flyer or brochure Preliminary Budget and Final Reporting Speaker Travel/Honoraria Processing without commercial support Speaker Travel/Honoraria Processing with commercial support Organization directly reimburses other expenses with or without commercial support Closing the File: Subsequent to the meeting the organization will furnish a complete file to TCMS that will include: List of attendees with name, address and contact information that is legible. Copies of the sign-in/registration form Copies of the CME certificates Summary of the evaluation forms Documentation to verify method of notifying participants of commercial support and speaker disclosure declarations. Final budget report will be submitted once all expenses have been received and reimbursed. TCMS Responsibilities: Administration: Publicity: Application consultation Grants AMA Category 1 Accreditation after approval of application packet Joint Sponsorship Coordination Complete session observation form Certificate of Attendance Review and approve brochure, flyer and/or announcement for publication.

LECTURE OBJECTIVES Please fill in the blanks with a short description of what you hope the participants will gain from your presentation. Lecture Title Lecture Date At the end of this lecture, participants will: 1. 2. 3. 4. PLEASE ATTACH A CURRENT CURRICULUM VITAE OR RESUME. PLEASE COMPLETE AND RETURN THE ENCLOSED W-9 FORM. PLEASE PROVIDE A COPY OF YOUR PRESENTATION BY EMAIL (OR MAIL) AT LEAST ONE WEEK PRIOR TO THE PRESENTATION. Please check HANDOUTS: I will have handouts with me. I will not have handouts. AV EQUIPMENT NEEDS: Honorarium Fee: $ Estimated Expenses $ Please Print Name: Please return this form to: TCMS 5315 S Lewis Ave Tulsa OK 74105

TULSA COUNTY MEDICAL SOCIETY CONTINUING MEDICAL EDUCATION POLICY AND PROCEDURE MANUAL SUBJECT: COMMERCIAL SUPPORT DATE: NOVEMBER 1, 2004, REVISED 8/25/06 The Policy on Commercial Support exists to provide guidance for staff and faculty in order to implement and comply with the Essential Areas and policies of the Oklahoma State Medical Association. A letter of agreement will be utilized whenever an activity receives commercial support. The unrestricted educational grant will be paid to Tulsa County Medical Society (TCMS) and all expenses of the program will be paid by TCMS. All continuing medical education activities provided by TCMS shall provide for an in-depth presentation that is independent, balanced and objective. TCMS is solely responsible for the administration, content, quality and integrity of all continuing medical education activities. Representatives from commercial supporters may attend an educational activity, but may not 1) engage in sales activities in the room where the activity takes place, 2) wear any type of name badge with the name of their company, 3) distribute any literature or products, or 4) discuss their product or company with any conference attendees during the educational activity. Acknowledgment will be made of any outside organization providing financial support of an educational activity. No commercial promotional materials shall be displayed or distributed in the same room immediately before, during or after a CME activity. TCMS will require faculty to disclose relevant financial relationships with any commercial supporter, relevant financial relationships with the manufacturers of products or competing products discussed in their presentation and unlabeled or unapproved uses discussed in their presentation to the participants. This information will be available to the participants of the CME activity in writing and by announcement CME activity promotional materials will acknowledge commercial supporters.