Application Type: (check one)
□ Initial certification $500
□ Additional sites (initial certification) $250
□Continuing certification $300
□  Additional sites (continuing certification) $150

AARC Use Only: 
Action Dates:
Received: __________
Approved __________
Incomplete__________
Rejected   __________
Assigned Program #
___________________

	Fee	Quantity	Amount	
ASME Fees				
Initial certification	$500			
Additional sites (initial certification) $250 each	$250			
Continuing certification	$350			
Additional sites (continuing certification) $150 each	$150			
Total Amount				

PAYMENT DUE AT TIME OF APPLICATION
Credit Cards or Checks only- No Purchase Orders 

If paying by credit card:
Check type of credit card
___Visa
___MasterCard
___American Express	

Account number: 	

Expiration Date:

If paying by check:
(1)	Enter check # 	
(2)	Make check payable to the AARC and mail check to ASME Program, AARC, 9425 N. MacArthur Blvd, Ste.100 Irving TX, 75063)

Sponsoring Organization’s Name and Address:

	

Primary Contact Person for Information in this Application 
Name:	
Mailing address:
	
Business phone:	Other phone:
	
Fax:	Email:

Program and Key Personnel Contact Information
Chief Administrative Officer
Name:	
Mailing address:
	
Business phone:	Other phone:
	
Fax:	Email:

ASME Program Coordinator
Name:	
Mailing address:
	
Business phone:	Other phone:
	
Fax:	Email:

ASME Program Medical Director
Name:	
Mailing address:
	
Business phone:	Other phone:
	
Fax:	Email:

ASME Program Site Locations

Identify each site where the ASME Program will be delivered.
Please duplicate this page if necessary to include all site locations.

Name of Facility	
Address

Name of site coordinator (if different from ASME Coordinator)	
Facility Phone ____________Facility Fax _______________	
Check appropriate service area description of this site:
Rural      Urban    Suburban	
Check method of delivering education at this site:
1:1     Group     Both	
Check the description that best describes type of program:
Community based  Free standing education center  Government or Public Health
Home health          Outpatient hospital                    Acute Care hospital
Pharmacy                Physician Practice                     
Other (describe) _____	

Name of Facility	
Address

Name of site coordinator (if different from ASME Coordinator)	
Facility Phone ____________Facility Fax _______________	
Check appropriate service area description of this site:
Rural      Urban    Suburban	
Check method of delivering education at this site:
1:1     Group     Both	
Check the description that best describes type of program:
Community based  Free standing education center  Government or Public Health
Home health          Outpatient hospital                    Acute Care hospital
Pharmacy                Physician Practice                   
 Other (describe)	

Other ASME Professional Personnel
Please duplicate this page if necessary to include all ASME professional team members

Name
	
Title
	
Profession-Check one
Respiratory Therapist       Nurse            Physician

Pharmacist    Social Worker 
Other (identify)____________________________	
Professional Credentials	
License # 
	License Expiration Date	

Name
	
Title
	
Profession-Check one
Respiratory Therapist       Nurse            Physician
Pharmacist    Social Worker 
Other (identify)____________________________	
Professional Credentials	
License # 
	License Expiration Date	

Name
	
Title
	
Profession-Check one
Respiratory Therapist       Nurse            Physician
Pharmacist    Social Worker 
Other (identify)____________________________	
Professional Credentials	
License # 
	License Expiration Date	

Instructions for Submitting the Appendices: 
1.	Create a separate file for each appendix and label each clearly (e.g Appendix 1, Appendix 2. etc) 
2.	Any documents supporting information contained in an appendix that are not part of the appendix file must have a title that includes the appendix to which it belongs (e.g Appendix 2-AE-C Program Director Certificate). 
Standard #1 Program Organization, Plan and Goals (Supporting Documents)

Attach an appendix (Appendix 1) that documents:
1.	A statement from the parent organization’s chief administrative officer indicating the organization’s commitment and support and how the ASME Program aligns with the parent organization’s overall structure and goals
2.	Clearly stated program goals and objectives that reflect the National Asthma Education and Prevention Program (NAEPP) “Expert Panel Report 3 Asthma Guidelines”
3.	A description of the methodology for measuring the program goals and objectives
4.	Documentation of the program's organizational structure that identifies personnel reporting relationships and channels of communication
5.	A description of the process used to identify and screen potential patients
6.	Documentation (algorithm, flow chart, outline, etc.) that clearly identifies and describes critical elements for asthma education and the program personnel responsible for each, which may include but are not limited to: 
a.	Initial contact and assessment
b.	Individualized plan of education
c.	Patient education
d.	Measurement of outcomes to determine success of the educational plan
e.	Follow-up and implementation
f.	continuous quality improvement 
Standard #2 Program Leadership (Supporting Documents)
Attach an appendix (Appendix 2) that contains:
1.	Medical director information:
a.	A job description 
b.	Current curriculum vitae - If the physician has not completed a fellowship in allergy/immunology or pulmonary medicine then additional documentation of experience or education in the treatment of asthma is required.  This can include: CME credits, letters of recommendation by board certified allergy/immunology or pulmonary physicians, research and publications
2.	Program coordinator information:
a.	A job description 
b.	A current curriculum vitae 
c.	Documentation of a current AE-C credential
3.	Evidence that the medical director and program coordinator participate in collaborative planning. This evidence can include but is not limited to minutes of planning meetings with documentation of medical director and coordinator attendance; medical director and program coordinator signatures on policies, procedures, plans of action and review of program outcomes.

Standard #3 Instructional Team (Supporting Documents
Attach an appendix (Appendix 3) for each member of the educational team that contains: 
1.	Their job description. 
2.	Evidence of their professional credentials and a current copy of their professional license.

Standard #4 Continuing Education (Supporting Documents)
Attach an appendix (Appendix 4) that documents the continuing education activity for each member of the educational team during the current and previous year. The following information is required for each educational activity:
1.	 the name of the educational activity
2.	location of the activity
3.	 the dates of attendance 
4.	the number of contact hours awarded 
5.	the sponsor of the course
6.	the name and address of the accrediting agency

Include a statement of attestation signed by the program coordinator that the educational activity of each professional team member is reviewed annually to assure that they have earned at least the 3 hours of continuing education each year.  

Standard #5 Identification of the Asthma Education Target Population and its Needs (Supporting Documents)
Attach an appendix (Appendix 5) that contains:
1.	Documentation of an updated annual population(s) needs assessment analysis.
2.	 A list of identified and prioritized problems with the strategies to address each area.
3.	Documentation that teaching materials and strategies are chosen based on identified needs and risks. 

Standard #6 Operational Support (Supporting Documents)
Attach an appendix (Appendix 6) that describes the operational resources required to enable the ASME Program to reach its goals.
1.	A description of the layout of the physical facilities that details the physical space of the facilities used to conduct the ASME Program activities
2.	A  budget for the current fiscal year that includes personnel, equipment, supplies, and other expenses of the ASME Program
3.	Evidence that resources required for the program are reviewed annually by the program coordinator and medical director.

Standard #7 Individual Needs Assessment (Supporting Documents)

Attach an appendix (Appendix 7) that contains an example of a typical individual needs assessment. This assessment can include documentation or assessment of:
1.	Relevant medical history and previous testing when available
2.	Current pulmonary function test (PFT) or peak flow results
3.	Asthma knowledge
4.	Self-management skills
5.	Perception of symptoms
6.	Asthma severity 
7.	Asthma control
8.	Individual goals and quality of life
9.	Knowledge of personal asthma triggers and their remediation
10.	Adherence or compliance issues or obstacles
11.	Competency in the use of prescribed medical devices including peak flow meters and medication delivery devices
12.	Barriers that impede asthma management including financial, transportation, psycho-social, etc.

Standard #8 Individual Education Plan (Supporting Documents)
Attach an appendix (Appendix 8) that provides an asthma plan of action.  The components of the individual education plan must include:
1.	Causes and treatment options for asthma
2.	Monitoring symptoms and/or peak flows as a means of determining control of asthma.
3.	Personal triggers.
4.	Environmental triggers and action to take.
5.	Use of medication delivery devices or therapies.
6.	Purpose and indication for asthma medications
a.	According to impairment and risk 
b.	According to symptoms
Standard #9 Individual Asthma Plan of Action Development
 (Supporting Documents)
Attach an appendix (Appendix 9) that contains an example of a typical asthma plan of action. This action plan must document specific circumstances in which asthma becomes out of control and provide appropriate action to minimize the impact of the exacerbation

Standard #10 Establishing Individual Patient Outcome Measures (Supporting Documents)
Attach an appendix (Appendix 10) that demonstrates how outcome measures are identified in the patient’s chart, and documents a patient’s performance before and after education intervention.

Standard # 11 Evaluating and Analyzing Outcomes to Improve the Program (Continuous Quality Improvement) (Supporting Documents)
Attach an appendix (Appendix 11) that provides:
1.	A description of a continuous quality improvement plan that reflects the goals of the program and the outcomes that have been identified and measured
2.	Documentation of a review of outcomes and resulting changes when outcomes do not meet stated organizational or individual goals

Standard #12 Record Keeping (Supporting Documents)
Attach an appendix (Appendix 12) that describes where patient records are maintained and who may access those records. Provide copies of policies related to the medical record access and storage. 

Program Requirements
I attest that the information contained within this application accurately describes the actual operations of this program and reflects all of the sites requesting certification.

Signed:
_________________________________                         ___________________
Chief Administrative Officer                                                 Date

_________________________________                         ___________________
ASME Coordinator                                                                Date	

Email completed applications and attachments to asme@aarc.org  You will receive a message confirming receipt within 2 business days. If you don’t receive confirmation, call the AARC at 972-243-2272 and ask to speak with the ASME coordinator.