Cover Page for Evaluation Form
(Name of Course)
(Date(s) of Course)
(Location of Course)
(Presenting group)
CONTINUING EDUCATION CREDIT
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of The National Institutes of Health/Foundation for Advanced Education in the Sciences (NIH/FAES) and <insert name of Regional Medical Library >. The NIH/FAES is accredited by the ACCME to provide continuing medical education for physicians.
The NIH/FAES designates this educational activity for a maximum of 5.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
To obtain certification of attendance, please complete this form. You may submit it at the conclusion of the course or mail the form to <insert RML administrative contract's name and address >.
Please indicate hours attended per day: I have attended the following session(s) of <Name of Conference>:
| (Date) | (total of X hours) | _____hours attended |
| (Date) | (total of X hours) | _____hours attended |
| (Date) | (total of X hours) | _____hours attended |
Certificate of attendance should be mailed to:
| Name, Professional Degree: | |
| Title: | |
| Organization: | |
| Street: | |
| City, State, ZIP: | |
| E-mail Address: | |
| Month and day of birth (not year): | |
| My medical specialty is: |
*Full Disclosure of Speaker Financial Interests or Relationships
Today's speaker has reported a financial interest or relationship with the following manufacturer(s) of commercial products, service, technology, or program that may be discussed in this educational presentation. Such interests are identified by the speaker so that participants may have these facts fully disclosed prior to the presentation, and may form their own judgments about the presentation.
| Company: | <insert name of Regional Medical Library> | Relationship: | |
| Company: | Relationship: |
Off-label or investigational drugs or devices to be discussed:
