ࡱ>  7bjbjLL ;.bc.bc*N 8) 5|SOr t!"lfNhNhNhNhNhNhN$-QSN&#r r &#&#N O8)8)8)&#vfN8)&#fN8)8)&G"KN#jH"RN#O0SOIT$2TD"K"KT6K&#&#8)&#&#&#&#&#NN8)&#&#&#SO&#&#&#&#T&#&#&#&#&#&#&#&#&# : COURSE INFORMATION (Please print or type) CourseTitle:  FORMTEXT       Requested Length of Activity:  FORMCHECKBOX 1 hour  FORMCHECKBOX 2 hours  FORMCHECKBOX 3 hours  FORMCHECKBOX 4 hours (Final course length may be determined by the Committee based on program needs and/or space available.) Needs Assessment What is the gap between current practice and best practice? What are plastic surgeons doing now that could or should be done differently or better? Why do we need this course? (Non-MD Practice Management Speakers Please submit a detailed course proposal and presentation slides for full consideration)  FORMTEXT       Anticipated Learner Outcome  Based on this course, learners should be able to apply new strategies in their practice. Please describe the new skill(s) the learner will be able to perform and the anticipated improvement in patient outcomes as a result of taking this educational activity (e.g.  implement the XXX technique to reduce the incidence of post-operative wound dehiscence ). Following this activity, the learner will be able to:1.  FORMTEXT      2.  FORMTEXT       Points to be Covered (please list the specific topics to be covered): 1. FORMTEXT      2. FORMTEXT      3. FORMTEXT       PROPOSED FACULTY (please include contact information for any non-ASPS members): Name:  FORMTEXT       ASPS ID #:  FORMTEXT       E-mail:  FORMTEXT       FORMTEXT       Address:  FORMTEXT       Phone:  FORMTEXT       FAX:  FORMTEXT       Name:  FORMTEXT       ASPS ID #:  FORMTEXT       E-mail:  FORMTEXT       FORMTEXT       Address:  FORMTEXT       Phone:  FORMTEXT       FAX:  FORMTEXT       Name:  FORMTEXT       ASPS ID #:  FORMTEXT       E-mail:  FORMTEXT       FORMTEXT       Address:  FORMTEXT       Phone:  FORMTEXT       FAX:  FORMTEXT       Name:  FORMTEXT       ASPS ID #:  FORMTEXT       E-mail:  FORMTEXT       FORMTEXT       Address:  FORMTEXT       Phone:  FORMTEXT       FAX:  FORMTEXT       COURSE CLASSIFICATION (LEVEL):  FORMCHECKBOX  INTRODUCTORY: Basic and fundamental knowledge.  FORMCHECKBOX  ADVANCED: Registrants are expected to have prior experience and a sound grasp of fundamental knowledge of the area.  FORMCHECKBOX  COMPREHENSIVE: Both introductory and advanced material presented. PRESENTATION METHODOLOGY (MODE):  FORMCHECKBOX  DIDACTIC: Formally organized presentation followed by a discussion period.  FORMCHECKBOX  WORKSHOP: Laboratory course requiring registrant participation to develop and experience technical skills.  FORMCHECKBOX PROBLEM ORIENTED: Course deals with avoidance and treatment of complications at an advanced level. Attendees asked to bring case example slides to discuss during course. This activity may contain content applicable to patient safety. If appropriate, please select the percentage of content applicable to patient safety topics:  FORMCHECKBOX  0%  FORMCHECKBOX  25%  FORMCHECKBOX  50%  FORMCHECKBOX  75%  FORMCHECKBOX  100% Select all of the patient safety topics which apply:  FORMCHECKBOX  Anesthesia care  FORMCHECKBOX  Appropriate patient selection  FORMCHECKBOX  Complications management  FORMCHECKBOX  Physical plant safety  FORMCHECKBOX  Prophylaxis measures  FORMCHECKBOX  Risk Management This activity addresses the following core competencies:  FORMCHECKBOX  Medical Knowledge  FORMCHECKBOX  Patient Care  FORMCHECKBOX  Interpersonal and Communication Skills  FORMCHECKBOX  Systems-based Practice  FORMCHECKBOX  Professionalism  FORMCHECKBOX  Practice-based Learning and Improvement This Activity addresses the following ABPS Tracer Procedures linked to Maintenance of Certification: Comprehensive Hand  FORMCHECKBOX  Reduction mammaplasty  FORMCHECKBOX  Carpal tunnel  FORMCHECKBOX  Breast reconstruction  FORMCHECKBOX  Dupuytrens contracture  FORMCHECKBOX  Pressure sores  FORMCHECKBOX  Thumb carpo-metacarpal arthritis  FORMCHECKBOX  Facial skin malignancy  FORMCHECKBOX  Flexor tendon laceration  FORMCHECKBOX  Lower-extremity wounds  FORMCHECKBOX  Metacarpal fractures Cosmetic Craniomaxillofacial  FORMCHECKBOX  Augmentation mammaplasty  FORMCHECKBOX  Cleft lip/Cleft palate  FORMCHECKBOX  Face lift  FORMCHECKBOX  Zygomatic fractures  FORMCHECKBOX  Liposuction  FORMCHECKBOX  Genioplasty  FORMCHECKBOX  Abdominoplasty  FORMCHECKBOX  Secondary nasal cleft deformity  FORMCHECKBOX  Blepharoplasty  FORMCHECKBOX  Non-syndromic craniosynostosis NOTE: Audiences at CME activities sponsored or co-sponsored by the American Society of Plastic Surgeons must be afforded the opportunity to properly evaluate information, analysis and opinions presented during the activity. It is important that the audience be informed of any aspect of a presenter's personal or professional circumstances out of which a perception of a conflict of interest would arise. A commercial interest is defined by the ACCME as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, with some exceptions, such as, eligible non-profit or government organizations, non-health care related companies, and providers of clinical service directly to patients. Circumstances calling for disclosure include, but are not limited to: receipt of financial support from a commercial interest, as defined above, for research activities or other scientific work reported on during the program, or, a personal financial or proprietary interest in, or consultant relationship to, a company that is a commercial supporter of the activity or whose product or service is discussed as part of the subject matter of the activity. Specifically, any financial relationship in any amount occurring in the last twelve (12) months (even if the relationship has been divested), including those of a spouse/partner, must be disclosed. A conflict of interest exists wherein an individual has or uses the opportunity to inject bias based on the held financial interest into the educational content or dissemination of related information. According to the ACCME, financial relationships create actual conflicts of interest in CME when individuals have both a financial relationship with a commercial interest and the opportunity to affect the content of CME about the products or services of that commercial interest, as defined above. Please list any commercial interest including name(s) of presenter and commercial entity (or indicate NONE):  FORMTEXT        PLEASE RETURN THIS FORM BY DECEMBER 1, 2016 TO: ASPS EXECUTIVE OFFICE, Attention: Mary Ellen Bogucki,  HYPERLINK "mailto:mbogucki@plasticsurgery.org" mbogucki@plasticsurgery.org or FAX 847-709-7516 PLASTIC SURGERY 2017 GUEST SPEAKER HONORARIUM AND EXPENSE REIMBURSEMENT GUIDELINES ASPS/ASMS Member with an active record. Registration fee is paid by the ASPS/ASMS Member themselves Social events are paid by the ASPS/ASMS Member themselves No honorarium payment provided No reimbursement of hotel or travel expenses No expense per diem ASPS/ASMS Non-Member but ABPS Board Certified Plastic Surgeon Complimentary registration provided Social events are paid for by the speaker themselves No honorarium provided No reimbursement of hotel or travel expenses No expense per diem ASPS/ASMS Residents/Fellows; ASPS/ASMS Applicants/International Members Registration fee is paid by the ASPS/ASMS Resident/Fellow Applicant/International Member themselves Social events are paid by the speaker themselves No honorarium provided No reimbursement of hotel or travel expenses No expense per diem ASPS Affiliate Member and All Practice Management Consultants Complimentary registration provided Social events are paid for by the speaker themselves No honorarium provided No reimbursement of hotel or travel expenses No expense per diem Guest Speakers not mentioned above No registration fee for pre-approved speakers only. Additional attendees accompanying guest speakers will be required to pay $50.00 per day for issuance of a meeting badge, allowable for the day of the guest speakers presentation only. Social events are paid by the guest speaker themselves Reimbursement of expenses for hotel nights determined based on number of program participation days, overseas travel, meeting location in relation to speakers origin and available flight schedule. Hotel reimbursement is done at the designated rate for single occupancy at the headquarters hotel only. Maximum number of nights reimbursed is at the discretion of the Society. 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Any amount approved for reimbursement will be based on comparable 21 day advance purchase roundtrip economy airfare, not to exceed $500.00. Travel for international speakers (not including Canada) will be reimbursed up to $1500.00. Miscellaneous expense per diem not to exceed $64.00 per day, for the day(s) of program participation, and travel periods only, to be determined by the program chair. This per diem is to cover miscellaneous expenses including meals not already provided as part of the meeting, parking, taxis, etc. Additional personal expenses including but not limited to hotel incidentals, telephone calls, gratuities, etc. are not reimbursed. The standard honorarium is $200.00. Any exception to this must be approved by the Scientific Program/ Instructional Course Program Chair in cooperation with the Executive Office. This must be done before the guest speaker is confirmed on the program, in order to review the program budget limitations A letter is sent to each guest speaker to confirm any honorarium or expense reimbursement to be provided. A check to cover honorarium, hotel reimbursement and per diem will be forwarded to the guest speaker following the meeting. Reimbursement for airfare will be forwarded following receipt of documentation. All Speakers Per the ACCME Standards for Commercial Support, must confirm via the ASPS Disclosure Form, that they will not accept any additional funds from a commercial entity for their presentation or attendance at the program. 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