ABORM COURSE APPLICATION PACKET ABORM CONTINUING EDUCATION COMMITTEE 910 Hampshire Road, Suite A Westlake Village, CA 91361 - I -
COURSE APPLICATION FORM Course Title: Course Instructor: Course Dates: Name of Provider: ABORM Provider #: Requested # of ABORM CE Hours: Language of Instruction: Contact Person: Course Location (Hotel and Street Address): City, State, Country, Zip Provider Phone: Fax: Website: E-mail: Bulk Rates $100 Live Course or Live Webinar $100 Webinar Ongoing $150 Multi-day Live Course (same subject) $200 Multi-day Online & Ongoing $250 Conference or Symposium $300 4-10 programs $400 11-16 programs $500 17-25 programs $600 26+ programs TOTAL - 2 -
Required Documents for Program Applications Select the type of program and attach the required documents to the application. PLEASE REFER TO CITATAION STANDARDS FOR ABORM-CERTIFIED COURSES IN PROVIDER APPLICATION PACKET WHEN SUBMITTING ALL COURSES Live Presentations (1 day course, seminar, or 10+ courses) Program Description - How does it relate to Oriental Reproductive Medicine? Goals and Objectives - 3 to 5 bullet points Presenter/Instructor Professional Resume - We do NOT accept biographical sketches Detailed Agenda - Calculated by 30 min increments Sample Sign-in Sheet Sample Certificate Include on both Sign-in & Certificate: provider name, course title, instructor, date, ABORM CEU s awarded, and your ABORM CE Provider # Conferences and Symposiums (multiple day course-multiple subjects) Program Brochure with Course Descriptions Presenters Biographical Sketch Detailed Agenda - Calculated by 30 min increments Sample Sign-in Sheet Sample Certificate Include on both Sign-in & Certificate: provider name, course title, instructor, date, ABORM CEU s awarded, and your ABORM CE Provider # Distance Learning Webinars/On-Line Courses Program Description - How does it relate to Oriental Reproductive Medicine? Goals and Objectives - 3 to 5 bullet points Presenter/Instructor Professional Resume - We do NOT accept biographical sketches Detailed Agenda - Calculate time frames for educational activities Sample End of Program Assessment-Test, Quiz, Paper, etc. Sample Certificate Include on both Sign-in & Certificate: provider name, course title, instructor, date, ABORM CEU s awarded, and your ABORM CE Provider # - 3 -
ABORM CE PROGRAM APPLICATION (cont.) By signing below, I affirm that the materials supplied herein are accurate, true, and correct in all respects, and that the ABORM CE Provider will abide by the ABORM policies, procedures, code of ethics, and the specific Provider Responsibilities as outlined in the ABORM CE Provider Application already submitted to ABORM. I understand the program review process takes approximately 4-6 weeks. Authorized Signature: Print Name: Date: - 4 -
PROGRAM APPLICATION CHECKLIST AND SUBMISSION INFORMATION Signed and completed Program Application Total from Program Application Form Program Description Goals and Objectives Presenter/Instructor Professional Resume Detailed Agenda Sample Sign-in sheet or assessment tool Sample certificate Check or Money Order payable in USD to ABORM Credit Card Name of Card Holder (First, Middle initial, Last) : Visa MasterCard Credit card # Expiration Date: / 3 digit security number on back of credit card: Billing Address/State/Zip: Send completed application to: ABORM CONTINUING EDUCATION COMMITTEE 910 Hampshire Road, Suite A Westlake Village, CA 91361-5 -
Course Description and Objectives Course Title: Instructor: Dates: Location: Course Description: Goals & Objectives: S e e e x a m p l e s i n c l u d e d i n t h e f o l l o w i n g p a g e s f o r t i p s o n f i l l i n g o u t t h e D e t a i l e d A g e n d a - 6 -
Course Name: Detailed Agenda Instructor Name: Course Type: Live, Online, distance learning, webinar Must be typewritten. To ensure proper consideration, please indicate the start and end times, a detailed explanation of the topic(s) covered in that hour, the Competency Code and the course content type. Definitions of the Competency Codes are shown on following pages, as well as full content descriptions and examples of courses of each type. One credit hour is equal to 60 minutes of instruction. Describe each credit hour (or portion of a credit hour) in a separate row. Competency Codes: RM = Reproductive Anatomy and Physiology Males, RF =Reproductive Anatomy and Physiology Females, A = Acupuncture, H = Chinese Herbal, ART, = Assisted Reproductive Techniques EP = Early Pregnancy, P =Pathology & Diagnosis, D= Western Diagnostic Methods, E = Ethics Course Content Type Codes: CM= Theoretical Chinese Medicine PA = Practical Application WM= Western Medicine O = Other (Explain how content relates to the practice of Acupuncture/Oriental Medicine) Credit Hours Detailed Explanation of Topic(s) to be Covered Competency Codes (circle all that apply) Course Content Type (circle all that apply) Total Hours Related to Reproductive Health Provider: Page of (Please make copies as needed) Competency Codes: - 7 -
RM = Reproductive Anatomy and Physiology: Males RF = Reproductive Anatomy and Physiology: Females A = TCM Treatment of Infertility Disease Patterns: Acupuncture H = TCM Treatment of Infertility Disease Patterns: Chinese Herbal Medicine ART = Indications/Procedures/Terminology/Medications involved in Assisted Reproductive Therapies EP = Early Pregnancy/Miscarriage/Recurrent Pregnancy Loss/Gestational Disorders P = Reproductive Pathology, causes and Differential Diagnosis for Infertility. This includes gynecological disorders such as PCOS, endometriosis, POF, etc but not menopause. D= Imaging/Labs/Surgery/Indications E = When to treat. When to refer, when to let go. Oriental Medicine (CM) Course Content Types Content related to Chinese medicine-knowledge of acupuncture, oriental medicine or medical ethics. Examples: Meridian Theory, Yin Yang, Zang Fu Organs, Five Elements, Eight Principles, Etiology, Body Fluids, Qi, Blood, Shen, Jing, Treatment Principles and Classics, Oriental Philosophy, Diagnosis, Case Studies, Medical Ethics, Risk Management. Practical Application (PA) Hands on course training and practicum s at FABORM clinics and IVF clinics. The application of knowledge relating to the practice of Oriental reproductive medicine. Examples: Acupuncture Technique, Point Location, Nutrition, Exercise, Oriental Massage, Acupressure, Moxibustion, observing IVF procedures. Western Medicine (WM) Content related to Western Medicine. Examples: Western physiology and anatomy, indications for referral, understanding of diagnostic testing analysis. Other (O) Please provide a detailed explanation in the space provided of how the course is related to the practice of Oriental Reproductive Medicine. Example: Teaching an ABORM-approved seminar. Content Not Related to the Practice of Acupuncture/Oriental Medicine No credit will be allowed for these types of courses. Examples: Courses which focus upon the practitioner s self-improvement or self-therapy, personal growth, self-awareness etc.; liberal arts courses in music, art, philosophy, and others unrelated to acupuncture or oriental medicine; all other courses not related to the practice of Acupuncture and/or Oriental Medicine. - 8 -
Detailed Agenda (Example I) Course Name: Men's Health and Male Infertility Instructor Name: Peter Deadman Course Type: Live, Online, distance learning, webinar Must be typewritten. To ensure proper consideration, please indicate the start and end times, a detailed explanation of the topic(s) covered in that hour, the Competency Code and the course content type. Definitions of the Competency Codes are shown on following pages, as well as full content descriptions and examples of courses of each type. One credit hour is equal to 60 minutes of instruction. Describe each credit hour (or portion of a credit hour) in a separate row. Competency Codes: RM = Reproductive Anatomy and Physiology Males, RF =Reproductive Anatomy and Physiology Females, A = Acupuncture, H = Chinese Herbal, ART, = Assisted Reproductive Techniques EP = Early Pregnancy, P =Pathology & Diagnosis, D= Western Diagnostic Methods, E = Ethics Course Content Type Codes: CM= Theoretical Chinese Medicine PA = Practical Application WM= Western Medicine O = Other (Explain how content relates to the practice of Acupuncture/Oriental Medicine) Credit Hours Detailed Explanation of Topic(s) to be Covered Competency Codes (circle all that apply) 0.5 Introduction The male patient & Male Crisis Four male disorders that can benefit form Acupuncture 1.0 Male Infertility Western Medicine How common is it Factors that affect male infertility Falling Sperm counts Assisted reproductive techniques to over come male infertility 0.5 Spermatogenesis and varicocele Physical exam and other causes of male infertility 0.5 Semen Analysis Basics, count, motility and morphology Viscosity, DNA fragmentation, Sperm antibodies 1.0 Male Infertility Acupuncture Zang Fu Kidneys Zang Fu Liver Zang Fu Spleen Channels Liver, Ren & Du 0.75 Diagnosis & Treatment by acupuncture Main acupuncture points Secondary acupuncture treatments ART EP P D E ART EP P D E ART EP P D E ART EP P D E 0.75 Lifestyle factors & Research on acupuncture for male infertility ART EP P D E Course Content Type (circle all that apply) Total Hours Related to Reproductive Health 5.0 Provider: Pro D Seminars Page of (Please make copies as needed) - 9 -
Detailed Agenda (Example II) Course Name: Treatment Protocols for Menopause and Endometriosis Instructor Name: Kiiko Matsumoto Program Description: This course will provide theoretical and practical applications to menopause and endometriosis from a Su Wen, Ling Shu and Nan Jing perspective as interpreted by Kiyoshi Nagano and Kiiko Matsumoto. Students will gain insight about the vast knowledge of Han dynasty classics integrated with modern day pathological disorders through the usage of a specialized form of Japanese style acupuncture. Goals and Objectives 1. Understand basics of Hara diagnosis as it relates to women's health 2. Learn about hormonal imbalances from a Nei Jing perspective 3. Diagnose pituitary, thyroid, ovarian and adrenal imbalances 4. Understand Bao and Chong Mai theory and applications Circle Course Type: Live Online Distance learning Webinar Must be typewritten. To ensure proper consideration, please indicate the start and end times, a detailed explanation of the topic(s) covered in that hour, the Competency Code and the course content type. Definitions of the Competency Codes are shown on the next page, as well as full content descriptions and examples of courses of each type. One credit hour is equal to 60 minutes of instruction. Describe each credit hour (or portion of a credit hour) in a separate row. Note: Time taken for simultaneous translation cannot be included in the hours requested for approved CEUs. Competency Codes: RM = Reproductive Anatomy and Physiology Males, RF =Reproductive Anatomy and Physiology Females, A = Acupuncture, H = Chinese Herbal, ART = Assisted reproductive techniques EP = Early Pregnancy, P =Pathology & Diagnosis, D= Western Diagnostic Methods, E = Ethics Course Content Type Codes: CM= Theoretical Chinese medicine PA = Practical Application WM= Western Medicine O = Other (Explain how content relates to the practice of Acupuncture/Oriental Medicine) - 10 -
Course Schedule Sheet (Example II Continued) Credit Hours 1.5 8:30am-10:00am Detailed Explanation of Topic(s) to be Covered Introduction: Basic hara diagnosis theory Competency Codes (circle all that apply) Course Content Type (circle all that apply) 1.0 10:15am-11:15am Oketsu: Blood stagnation, reflex zones and treatment points 1.0 11:15am-12:15pm Thyroid: Hypothyroid, hyperthyroid, toxicity, radiation, reflex zones and treatment points 1.5 1:15pm-2:45pm Adrenals: Adrenal exhaustion theory and treatment, classic adrenal imbalance, Dai Mai, toxicity, thyroid, basilary and cervical artery, reflex zones and treatment points 1.0 3:00pm 4:00pm Ovaries: Reflex zones and treatment points 1.5 4:00pm 5:30pm Live Demo - Hands on application 2.0 8:30am-10:30am Bao Mai: Trajectories, applications, reflex zones and treatment points 2.0 10:30-12:30 Chong Mai: Trajectories, applications, reflex zones and treatment points 1.0 Does not relate to reproductive medicine 1:15pm 2:15pm 1.0 3:00pm 4:00pm Etiology of menopausal syndrome Etiology of endometriosis 1.0 4:00pm 5:00pm Patient and volunteer student treatments - Endometriosis 0.5 Menopause does not relate to reproductive medicine 5:00 5:30pm Patient and volunteer student treatments - Menopause Total Hours Related to Reproductive Health 13.5 Provide name & number: Page of Please make copies as needed. - 11 -
Sample PARTICIPANT EVALUATION FORM (Must be retained by provider for 4 years) CE Provider Name and Number Date(s) of Course Course/Seminar Title Instructor Name Participant s Name and License Number Date of Evaluation Excellent 5 Very Good 4 Good 3 Fair 2 Poor 1 The content of the program met my expectations. Goals and objectives were defined at the beginning of the program. The length of the program was adequate to cover the required information. The lecturer/online information was knowledgeable of the subject matter. The lecturer/online tutorial was creative in presenting the materials I will be able to apply what I learned in my professional life. I received a certificate that documented the number of CEU s/hours awarded. I received an agenda and the instructor/online tutorial kept to the time frames. Additional Comments: - 12 -
Sample CERTIFICATE OF COMPLETION if approved for multiple boards THIS IS TO CERTIFY THAT HAS SUCCESSFULLY COMPLETED HOURS OF CONTINUING EDUCATION. Course Title Completion Date Provider Name: Provider No.: Instructor s Signature: Date: Provider s Authorized Signature: Date: NCCAOM (provider # - Course approval number) CAB (provider # - Course approval number) ABORM (provider # - Course approval number) PDA CEU CEU - 13 -
Sample CERTIFICATE OF ONLINE COURSE COMPLETION THIS IS TO CERTIFY THAT HAS SUCCESSFULLY COMPLETED Learning/Online hours. Distance Course Title Completion Date Provider Name: Provider No.: Provider s Authorized Signature: Date: NCCAOM (provider # - Course approval number) CAB (provider # - Course approval number) ABORM (provider # - Course approval number) PDA CEU CEU - 14 -