CVME Application & Planning Worksheet Section 1 of 5

 CVME Application & Planning Worksheet This form attempts to collect information necessary to plan and develop the proposed CVME course. CVME staff are available to help you navigate this process. Please note that this is for in‐person, live courses (symposium, workshop, conference, etc.). If you are proposing a webinar or on‐demand online course please fill out CVME Internet Course Proposal. Section 1 of 5: Activity Description Course Information Title Course Presented by Department Division(s) Date Time Attach additional dates, times and locations if necessary Location Sponsorship (Note: a pharmaceutical company or medical device manufacturer is not a sponsor.) Directly Sponsored (WSU department works with WSU CVME) Jointly sponsored (WSU works with non‐accredited provider – List Company Name(s): Co‐sponsored (WSU works with another accredited provider – List Company Name(s): Section 2 of 5: Leadership & Administrative Staff Support1 Course Director (CD) The veterinarian, technician or scientist with overall responsibility for program development. Name Degree(s) Title Affiliation Department Phone Email Administrative Coordinator/CVME Associate The individual responsible for the operational and administrative support of the certified course (usually administrative or staff assistant in the Department/Unit of the CD or the CVME Office). Name Title Department Phone Fax Email 1
The CD, administrative coordinator (if applicable) and planning committee members will be required to complete the WSU CVME Disclosure Form.
CVME Application & Planning Worksheet If you would rather have the CVME Office handle the section below, please write CVME in the Name section. Section 3 of 5: Planning Planning Committee In addition to the CD and/or CVME associate, fill out the following for those responsible for the design and implementation of this course. Use additional sheets if necessary.1 Name Degree(s) Title Name Affiliation Title Name Affiliation Email Degree(s) Email Degree(s) Title Affiliation Email Attach additional planning committee members’ information if necessary. 1The CD, administrative coordinator (if applicable) and planning committee members will be required to complete the WSU CVME Disclosure Form. Planning Process Have speakers been identified? Yes No If No, would you like CVME to help locate speakers? Yes No If YES, Please provide contact information for the speakers on a separate sheet. Target Audience Select all that apply (at least 1 box from geographic location, provider type, specialty, and animal type must be selected). Geographic Location: Internal only Provider Type: Veterinarians Specialty: All specialties Ophthalmology Animal Type: All Animals Local/regional National/International Veterinary Technicians Other (specify) Anesthesiology Cardiology Orthopedics Pharmacology Avian Camelids Clinical Pathology Dermatology Preventative Medicine Radiology Cats Cattle Emergency Medicine Internal Medicine Neurology Oncology Regulatory Medicine Surgery Theriogenology Other (specify) Dogs Equine Exotics Sheep/Goats Swine Other (specify) CVME Application & Planning Worksheet Section 4 of 5: Needs Assessment and Educational Design Note: Identification of gaps, needs, etc. should be completed by the Planning Committee. Please use the table below to complete this section, starting from the left column. All learning objectives should map to the educational need that is identified. Please use the action verbs (provided by Bloom’s Taxonomy) for the learning objectives. Use Knowledge level verbs if your gap is in knowledge, comprehension level verbs if your gap is in competence and levels in application and above for gaps that may be in performance. EXAMPLE Practice Gap/ Educational Need EXAMPLE This is a gap/need of: EXAMPLE Current Practice EXAMPLE Ideal Practice Veterinarians submit samples to WADDL to help with individual animal and herd diagnoses. However, not all of those samples are useable or diagnostic. Veterinarians are able to address any animal mortality issue and ensure consistent application of necropsy and sample submission guidelines. Current Practice Ideal Practice Practice Gap/ Educational Need This is a gap/need of: Knowledge Competence3 Performance4 Knowledge Competence Performance Knowledge Competence Performance Veterinarians need X Knowledge educational X Competence initiatives related to Performance necropsy and sample submission guidelines. EXAMPLE Learning Objective Describe current guidelines for necropsy and sample submission and identify resources for submission to the lab. Implement a new necropsy protocol for a specific disease syndrome. Learning Objective2
Attach additional needs/gaps, objectives, desired results if necessary. 2
Objectives should bridge the gap between the identified need/gap and the desired result. These are the take‐home messages; what should the learner be able to accomplish after the activity? 3
Competence is defined as the ability to apply knowledge, skills, and judgment in practice (knowing how to do something). 4
Performance is defined as what one actually does in practice.
CVME Application & Planning Worksheet Evaluation and Outcomes Measurements How will you measure if changes in competence, performance or patient outcomes have occurred? Select all that apply. Competence Evaluation form for participants Veterinarian or Veterinary Technician surveys Audience response system Other (specify): Custom pre and post‐test Performance Adherence to guidelines Chart audits Case‐based studies Direct observations Customized follow‐up survey/interview/focus group about actual change in practice at specified intervals Other (specify): Educational Design/Methodology Please indicate the educational method(s) that will be used to achieve the stated goal and objectives. Select all that apply. Didactic Lecture Panel discussions Roundtable discussions Q&A sessions Case presentations Simulations Hands on Skills Training Other (specify): Section 5 of 5: Additional Information Commercial Support and Exhibits Will this activity receive commercial support (financial or in‐kind grants or donations) from a company such as a pharmaceutical, animal nutrition or medical device manufacturer? [Note: exhibit fees are not considered commercial support.] Yes No Will vendor/exhibit tables be allowed at this activity? Yes No Preliminary Budget We strongly encourage you to use the WSU CVME budget template. If you have your own template, please ensure that projected income and expenses are listed in detail. Participant Registration WSU CVME has the ability to capture registrations and associated payments. Registration reports are provided and registration fees are transferred to a department fund code. Would you like to utilize WSU CVME registration service? Yes No Advertising Planning Please describe your advertising needs: