{"id":17,"date":"2023-08-11T21:48:53","date_gmt":"2023-08-11T21:48:53","guid":{"rendered":"https:\/\/keck.usc.edu\/cme\/?page_id=17"},"modified":"2023-08-11T22:03:51","modified_gmt":"2023-08-11T22:03:51","slug":"forms","status":"publish","type":"page","link":"https:\/\/keck.usc.edu\/cme\/forms\/","title":{"rendered":"Forms"},"content":{"rendered":"\n\n\n\n\n  \n\n  \n    \n\n\n\n\n\n\n<div\n  class=\"cc--component-container cc--hero-primary horizontal-navigation\"\n\n  \n  \n  \n  \n  \n  \n  >\n  <div class=\"c--component c--hero-primary\"\n    \n      >\n\n    \n  \n  <div class=\"inner-wrapper has-horizontal-nav\">\n\n          <div class=\"title-wrapper\">\n\n                  <div class=\"eyebrow-container\">\n                              \n<div class=\"f--field f--eyebrow\">\n\n    \n  <a href=\"https:\/\/keck.usc.edu\/cme\/\"  aria-label=\"Read more about Continuing Medical Education\">Continuing Medical Education<\/a>\n\n\n\n<\/div>\n                      <\/div>\n        \n                      \n<div class=\"f--field f--page-title has-stripe\">\n\n    \n  <h1>Forms<\/h1>\n\n\n<\/div>\n        \n              <\/div>\n    \n              \n<div class=\"f--field f--link eyebrow-link\">\n\n    \n    \n  \n<a\n  class=\"link \"\n  href=\"https:\/\/www.keckmedicine.org\/find-a-doctor\/\"\n  target=\"_blank\"  aria-label=\"Read&#x20;more&#x20;about&#x20;Are&#x20;You&#x20;a&#x20;Patient&#x3F;\">\n        Are You a Patient?\n    <\/a>\n\n\n<\/div>\n    \n    \n      \n              <div class=\"horizontal-nav\">\n                      <div class=\"horizontal-menu-container\">\n              <button class=\"expand-menu\">\n                                  In This Section\n                                <svg class=\"menu\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\"\n                  y=\"0px\" viewBox=\"0 0 35 35\" enable-background=\"new 0 0 35 35\" xml:space=\"preserve\">\n                  <path fill-rule=\"evenodd\" clip-rule=\"evenodd\" fill=\"#000\" d=\"M4,23h3v3H4V23z M4,16h3v3H4V16z M10,23\n                  h21v3H10V23z M10,16h21v3H10V16z M10,9h21v3H10V9z M4,9h3v3H4V9z\"\/>\n                <\/svg>\n\n                <svg class=\"close\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\"\n                  viewBox=\"0 0 35 35\" enable-background=\"new 0 0 35 35\" xml:space=\"preserve\">\n                  <polygon fill=\"#000\" fill-rule=\"evenodd\" clip-rule=\"evenodd\" points=\"26,10.4 24.6,9 17.5,16.1 10.4,9 9,10.4 16.1,17.5\n                  9,24.6 10.4,26 17.5,18.9 24.6,26 26,24.6 18.9,17.5 \"\/>\n                <\/svg>\n              <\/button>\n\n              <nav\n  class=\"mc--menu mc--\"\n  >\n  <ul class=\"m--menu m--\">\n    \n    \n      <li class=\" menu-item menu-item-type-post_type menu-item-object-page menu-item-home menu-item-11\">\n      <a href=\"https:\/\/keck.usc.edu\/cme\/\" >Continuing Medical Education<\/a>\n  \n  \n<\/li>\n\n    \n      <li class=\" menu-item menu-item-type-custom menu-item-object-custom menu-item-16\">\n      <a href=\"https:\/\/keckusc.cloud-cme.com\/default.aspx\" target=\"_blank\">Calendar and Related Information<\/a>\n  \n  \n<\/li>\n\n    \n      <li class=\" menu-item menu-item-type-post_type menu-item-object-page menu-item-22\">\n      <a href=\"https:\/\/keck.usc.edu\/cme\/forms\/\" >Forms<\/a>\n  \n  \n<\/li>\n\n    \n      <li class=\" menu-item menu-item-type-post_type menu-item-object-page menu-item-15\">\n      <a href=\"https:\/\/keck.usc.edu\/cme\/contact\/\" >Contact<\/a>\n  \n  \n<\/li>\n\n    \n      <\/ul><!-- m--menu -->\n<\/nav>\n\n            <\/div>\n                  <\/div>\n        <\/div>\n\n\n  <\/div><\/div>\n\n\n  \n    \n\n\n\n\n\n\n<div\n  class=\"cc--component-container cc--spacer \"\n\n  \n  \n  \n  \n  \n  \n  >\n  <div class=\"c--component c--spacer\"\n    \n      >\n\n    \n\n  <\/div><\/div>\n\n\n\n\n\n\n          \n  \n    \n\n\n\n\n\n\n<div\n  class=\"cc--component-container cc--accordions \"\n\n  \n   aria-label=\"Content Accordions\"\n  \n  \n  \n  \n  >\n  <div class=\"c--component c--accordions\"\n    \n      >\n\n    \n      <div class=\"header-container\">\n\n                  \n<div class=\"f--field f--section-title\">\n\n    \n  <h2>\n          CME-Related Forms\n      <\/h2>\n\n\n<\/div>\n      \n      \n    <\/div>\n  \n      <ul>\n              <li>\n          <button type=\"button\" class=\"accordion-trigger \" id=\"heading-1-1-p25HB9gg1M\" aria-controls=\"section-1-1-p25HB9gg1M\" aria-expanded=\"false\" aria-disabled=\"false\">\n                          <span class=\"item-title\">Applications for CME Accredited Activities<\/span>\n            \n                      <\/button>\n\n          <div id=\"section-1-1-p25HB9gg1M\" role=\"region\" aria-labelledby=\"heading-1-1-p25HB9gg1M\" class=\"accordion-panel\">\n\n                            \n    \n\n\n\n\n\n\n<div\n  class=\"cc--component-container cc--rich-text \"\n\n  \n  \n  \n  \n  \n  \n  >\n  <div class=\"c--component c--rich-text\"\n    \n      >\n\n    \n  <div class=\"inner-wrapper\">\n        \n<div class=\"f--field f--wysiwyg\">\n\n    \n  <ul>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/CME-Primer_FY13-14.pdf\">Guide for Planning and Delivering CME Accredited Activities<\/a><\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/CME-Event-Proposal-Approval-Application_2013.pdf\">CME Event Proposal Approval Application<\/a><\/li>\n<li>CME Activity Planning Document_Full Service<\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/CME-Activity-Planning-Document_Joint-Co-Sponsorship.pdf\">CME Activity Planning Document_Joint\/Co Providership<\/a><\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/CME-Activity-Planning-Document_Partial-Service.pdf\">CME Activity Planning Document_Partial Service<\/a><\/li>\n<\/ul>\n\n\n\n<\/div>\n  <\/div>\n\n\n  <\/div><\/div>\n            \n                      <\/div>\n        <\/li>\n\n              <li>\n          <button type=\"button\" class=\"accordion-trigger \" id=\"heading-1-2-p25HB9gg1M\" aria-controls=\"section-1-2-p25HB9gg1M\" aria-expanded=\"false\" aria-disabled=\"false\">\n                          <span class=\"item-title\">CME Regularly Scheduled Series (RSS) Application (i.e., Grand Rounds, Tumor Boards, M&#038;M, etc.)<\/span>\n            \n                      <\/button>\n\n          <div id=\"section-1-2-p25HB9gg1M\" role=\"region\" aria-labelledby=\"heading-1-2-p25HB9gg1M\" class=\"accordion-panel\">\n\n                            \n    \n\n\n\n\n\n\n<div\n  class=\"cc--component-container cc--rich-text \"\n\n  \n  \n  \n  \n  \n  \n  >\n  <div class=\"c--component c--rich-text\"\n    \n      >\n\n    \n  <div class=\"inner-wrapper\">\n        \n<div class=\"f--field f--wysiwyg\">\n\n    \n  <ul>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/RSS_app_FY2014-15.pdf\">Regularly Scheduled Series Application<\/a><\/li>\n<\/ul>\n<p>Please contact a CME Specialist for instructions on how to complete the Regularly Scheduled Series application: (323) 442-2555 or by email <a href=\"mailto:usccme@usc.edu\">usccme@usc.edu<\/a>.<\/p>\n\n\n\n<\/div>\n  <\/div>\n\n\n  <\/div><\/div>\n            \n                      <\/div>\n        <\/li>\n\n              <li>\n          <button type=\"button\" class=\"accordion-trigger \" id=\"heading-1-3-p25HB9gg1M\" aria-controls=\"section-1-3-p25HB9gg1M\" aria-expanded=\"false\" aria-disabled=\"false\">\n                          <span class=\"item-title\">Disclosure Forms<\/span>\n            \n                      <\/button>\n\n          <div id=\"section-1-3-p25HB9gg1M\" role=\"region\" aria-labelledby=\"heading-1-3-p25HB9gg1M\" class=\"accordion-panel\">\n\n                            \n    \n\n\n\n\n\n\n<div\n  class=\"cc--component-container cc--rich-text \"\n\n  \n  \n  \n  \n  \n  \n  >\n  <div class=\"c--component c--rich-text\"\n    \n      >\n\n    \n  <div class=\"inner-wrapper\">\n        \n<div class=\"f--field f--wysiwyg\">\n\n    \n  <ul>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/Faculty-Disclosure_Attestation-Forms1.pdf\">Financial Disclosure and Attestation Forms<\/a><\/li>\n<\/ul>\n\n\n\n<\/div>\n  <\/div>\n\n\n  <\/div><\/div>\n            \n                      <\/div>\n        <\/li>\n\n              <li>\n          <button type=\"button\" class=\"accordion-trigger \" id=\"heading-1-4-p25HB9gg1M\" aria-controls=\"section-1-4-p25HB9gg1M\" aria-expanded=\"false\" aria-disabled=\"false\">\n                          <span class=\"item-title\">Tools<\/span>\n            \n                      <\/button>\n\n          <div id=\"section-1-4-p25HB9gg1M\" role=\"region\" aria-labelledby=\"heading-1-4-p25HB9gg1M\" class=\"accordion-panel\">\n\n                            \n    \n\n\n\n\n\n\n<div\n  class=\"cc--component-container cc--rich-text \"\n\n  \n  \n  \n  \n  \n  \n  >\n  <div class=\"c--component c--rich-text\"\n    \n      >\n\n    \n  <div class=\"inner-wrapper\">\n        \n<div class=\"f--field f--wysiwyg\">\n\n    \n  <ul>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/Gap-Analysis-Worksheet.pdf\">Gap Analysis Worksheet<\/a><\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/Gap-and-LO-directions.pdf\">Guide to Writing Learning Objectives<\/a><\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/CheckList_FY2014-15.pdf\">Application Checklist<\/a><\/li>\n<\/ul>\n\n\n\n<\/div>\n  <\/div>\n\n\n  <\/div><\/div>\n            \n                      <\/div>\n        <\/li>\n\n              <li>\n          <button type=\"button\" class=\"accordion-trigger \" id=\"heading-1-5-p25HB9gg1M\" aria-controls=\"section-1-5-p25HB9gg1M\" aria-expanded=\"false\" aria-disabled=\"false\">\n                          <span class=\"item-title\">RSS Tool Kit<\/span>\n            \n                      <\/button>\n\n          <div id=\"section-1-5-p25HB9gg1M\" role=\"region\" aria-labelledby=\"heading-1-5-p25HB9gg1M\" class=\"accordion-panel\">\n\n                            \n    \n\n\n\n\n\n\n<div\n  class=\"cc--component-container cc--rich-text \"\n\n  \n  \n  \n  \n  \n  \n  >\n  <div class=\"c--component c--rich-text\"\n    \n      >\n\n    \n  <div class=\"inner-wrapper\">\n        \n<div class=\"f--field f--wysiwyg\">\n\n    \n  <ul>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/Clinical-Content-Review-Form-1.docx\">Clinical Content Review Form<\/a><\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/Credit-Tracking-Report_2014-15-1.xlsx\">Credit Tracking Report<\/a><\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/Directors-ReportFY201415-1.doc\">Director\u2019s Report<\/a><\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/Faculty-Disclosure_Attestation-Forms11-1.pdf\">Faculty Disclosure Forms<\/a><\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/report_form_1st_qtr_14-15-1.xls\">1st Quarter Report Form<\/a><\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/report_form_2nd_qtr_14-15-1.xls\">2nd Quarter Report Form<\/a><\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/report_form_3rd_qtr_14-15-1.xls\">3rd Quarter Report Form<\/a><\/li>\n<li>4th Quarter Report Form<\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/RSS-invite-letter_template-1.docx\">RSS Invite Letter Template<\/a><\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/RSS_Announce_Template_14-15-1.doc\">RSS Announcement Template<\/a><\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/RSS_sign-in_journal_club_14-151-1.doc\">RSS Sign-in Template<\/a><\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/RSS_Eval_Template_FY2014-15-2.doc\">RSS Eval Template<\/a><\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/ann_eval_14-15-1.doc\">RSS Annual Eval Template<\/a><\/li>\n<li><a href=\"https:\/\/keck.usc.edu\/cme\/wp-content\/uploads\/sites\/21\/2023\/08\/ann_eval_sampl_tally_14-15-1.doc\">RSS Annual Eval Tally Template<\/a><\/li>\n<\/ul>\n\n\n\n<\/div>\n  <\/div>\n\n\n  <\/div><\/div>\n            \n                      <\/div>\n        <\/li>\n\n          <\/ul>\n  \n\n  <\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-17","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.3 (Yoast SEO v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Forms - Continuing Medical Education<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/keck.usc.edu\/cme\/forms\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Forms\" \/>\n<meta property=\"og:url\" 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