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CME Credit Attestation Form Multiple Day activity Request for .doc

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CME Credit Attestation Form  Multiple Day activity  Request for .doc Powered By Docstoc
					                                        CME Credit Attestation Form
                 Please complete & return this form ONLY if you would like to receive CME credit.

Name of Activity:
Dates of Activity:

Please clearly PRINT information:

First Name:                                        MI:               Last Name:

Degree of Participant:         MD         DO        PA         RN        Other (please specify):

Organization:                                                                7-digit Duke ID (if applicable):

Specialty:                                                 Email:
                                                                             Note: CME certificates will be issued via email.
Mailing Address:

City:                                                               State:                       Zip Code:

Telephone Number: (               )                                          Fax#: (              )

   Date                               Signature                          Maximum Credits                  Credits Claimed*
                                                                                     X.X

                                                                                     X.X

                                                                                     X.X

                                                                                     X.X

                           Total CME Credits Claimed:                                X.X

*Individuals participating as a learner in this activity can claim 1 credit for each hour of participation
(not to exceed          credits).

Note to Meeting Faculty:
                                                    TM
Physicians may claim AMA PRA Category 1 Credit directly from the AMA for learning that occurs as a result of teaching
                                                             TM
at a live activity designated for AMA PRA Category 1 Credit . You may only claim credit once for a repeated
presentation, and cannot claim credit if you have already been awarded credit for the same presentation. Supporting
documentation requirements include a program or announcement indicating speakers, accredited providers, dates and
locations of the activity. The AMA will award 2 credits per hour of interaction. For more information, contact the American
Medical Association 312-464-5296, http://www.ama-assn.org.

I attest that the number of CME credits claimed above is accurate.


                                 Signature                                                       Date

To receive CME credit for this activity, this form must be completed in full and returned along with the activity evaluation to
                              the appropriate representative at the conclusion of the activity.
             A certificate of credit will be e-mailed to the requesting participant within 8 weeks of receipt.


  Duke Office of CME  3100 Tower Blvd, Suite 1300  Durham, NC 27707  Tel: 919/401-1200  FAX: 919/401-1213

				
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