E Xpert Reviewer Release Statement (For Use By Expert

e xpert reviewer release statement (for use by expert reviewers, expert panel) requirements: this form must be completed and signed b

E xpert Reviewer Release Statement
(For use by Expert Reviewers, Expert Panel)

Requirements: This form must be completed and signed by the Expert
Reviewer in accordance with Guideline S3-2 (Expert Review) and
included with the learning activity/program submission to CCCEP.
If major revisions are made to the learning activity/program following
submission to CCCEP, the Expert Reviewer must approve the final
content and format.
NOTE: This form is designed to be completed by electronic means. If
completing by hand, please expand boxes or add additional pages to
accommodate handwritten comments.
Learning Activity/Program to be Expert Reviewed
Learning activity/program Information
Learning activity/ program Title
Program Provider(s) and/or Developer(s)
Sponsor(s)
Expert Reviewer
Expert Reviewer Information
Name (First and Last)
Position
Employer/Facility
Mailing Address
(Street Address or P.O. Box #)
(city, prov, postal code)
Phone (Office or home)
Cell phone
E-mail
Education Credentials
(Credential, Granting Institution, Year)
Qualifications for Expert Review
Please complete the following statement
(Refer to education, work experience, research, writings, etc.)
I believe that I am qualified to be an Expert Reviewer for this
learning activity/program because: (If to be completed by hand, must
be written legibly.)
Purpose of the Expert Review:
To review the therapeutic and subjective content of the entire
learning activity/program including the post test and answer key
rationale (where applicable) for clinical relevance, unbiased
presentation, completeness, accuracy, and appropriateness of
references
Expert Review of the Learning Activity/Program
Step 1: Review the learning activity/program and comment on the
content and presentation of the learning activity/program, including
post-test and answer key rationale if applicable. This may be done on
the learning activity/program material OR on in a separate document.
The provider may consolidate these comments into one document, along
with the author’s responses, for submission to CCCEP.
Step 2: Complete the checklist and comment, with specific references
to the learning activity/program content.
Step 3: Complete Qualifications of Expert Reviewer.
Step 4: Complete the Declaration of the Expert Reviewer.
Step 5: Sign the Declaration (This form may be digitally signed by the
Expert Reviewer).
Step 6: Send to program provider.
Checklist and Specific Comments
The Expert Reviewer may make comments about specific criteria (or
reference to a page in the materials where the comment is made).
General comments about the learning activity/program may be made in
the section following the table. If appropriate and readily available,
it is helpful if the expert reviewer provides the author with the
reference information when suggesting significant content changes.
Criteria
Meets Criteria
Comments
Yes
No
N/A
1.
Is the title informative and descriptive of the learning
activity/program?
2.
Are the objectives of this learning activity/program clearly
stated?
3.
Are the objectives reasonable/achievable
4.
Is the content accurate and complete based on the objectives?
5.
Does the content of the learning activity/program fulfil the
stated objectives?
6.
Is the difficulty level of this learning activity/program
appropriate to the intended audience?
7.
Is the content presented in an unbiased manner?
8.
Is the format appropriate for the content being delivered?
9.
Are clinical tasks explained or demonstrated appropriately?
10.
Does the information in the learning activity/program adhere to
relevant existing national and international standards or
guidelines?
11.
Are references included, appropriate, and properly recorded?
General/Other Comments:
General comments may be about the organization of the learning
activity/program, overall perceptions of the content and topics, the
flow of the learning activity/program, the ease of navigating an
on-line learning activity/program, the conciseness of the text, the
style or grammar of the learning activity/program, etc., such as “nice
division of topics,” “could use some more content on (topic are),”
etc.
Declaration of Expert Reviewer
RE:
Enter Title of Program on following line
I affirm that I participated in all aspects of the development of the
above stated learning activity/ program and that I have reviewed and
critiqued the therapeutic and subjective content of the final draft of
the learning activity/program including the post-test and answer key
rationale (where applicable) for clinical relevance, unbiased
presentation, completeness, accuracy, and appropriateness of
references. It is my opinion that the learning activity/program
presents current, accurate, complete and balanced information on the
best available current research evidence and best practices in the
subject area.
I confirm that:
*
I am not an author or presenter of this learning activity/program;
*
I am not an employee or advisory board member of the program
provider or sponsor;
*
I do not have a current or recent financial or other relationship
with the program provider or program sponsor
*
I do not work closely with the author or presenter and I do not
work at the same facility/ institution; and
*
I do not have any other conflicts of interest.
[NOTE: If you uncertain if a situation may be a potential conflict of
interest, contact the Executive Director of CCCEP]
I approve this learning activity/program for submission for
accreditation review as follows:
Place “X” in left column for one option
Approved as reviewed (i.e. no revisions required)
Not Approved
Comment/Explanation:
*
I affirm this declaration by signing in the box below:
Signature of Expert Reviewer
Date Signed
Note: The Expert Reviewer may digitally sign and submit this form in
PDF format.
Canadian Council on Continuing Education in Pharmacy
Le Conseil canadien de l'éducation permanente en pharmacie