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					                                                                   Remote Site Coordinator - Group Registrations
                                                                                          Enclosed Packet
                                                           A.   Remote Site Coordinator’s instruction sheet
                                                           B.   Flyer for current lecture
 CME Videoconference                                       C.   Sign in Sheets
 Regularly Scheduled Series                                D.   Evaluation
 (RSS/Grand Rounds)                                        E.   2010 YAFI Course Announcement
 Distance Education (DE)                                   F.   Registration Form (for new/update participant information)

Instructions
At the RSS have on table (next to sign in sheets)
1. Flyer for current lecture with Speaker Disclosure/ Course Objectives/ Credit Designation
2. Evaluation Forms
3. Registration Form (for new/update participant information)
4. Cultural and Linguistic Competency handout
     Available on UCD/ CME Website (http://cme.ucdavis.edu), under the “Resources” link



                                  COVER SHEET
                SEND BACK TO RSS COORDINATOR: REGISTRATION PACKET
  CHECK LIST :
     Sign in sheets – your site’s name MUST be on the sign in sheet form or packet is considered incomplete
     Evaluation forms
     New/update participant information sheet
     Use this as your cover sheet and put on top of packet before sending back


   Complete Packet –
   Mail or fax back to DE CME Coordinator:                             DATE: _____________

   TO:          Gwenn Welsch                                           FROM: _____________________________
   FAX:         (916) 734-0776
                                                                       PHONE:_____________________________
   Address: 3560 Business Drive, Suite 130
            Sacramento, CA 95820                                       FAX: ________________________________


 Gwenn V. Welsch                                RSS PACKETS ARE DUE IN THE CME OFFICE WITHIN ONE WEEK AFTER THE ACTIVITY
 Office of Continuing Medical Education
 Distance Education and Webmaster               ATTENTION RSS site COORDINATORS: Review documentation to ensure that all
 UC Davis Health System                         items are attached. Incomplete packets will be returned to you. When you resubmit
 3560 Business Drive, Suite 130,                complete documentation, attendance will be entered in the transcript system.
 Sacramento, California 95820
 Phone:(916) 734-5773                           CME credit:
 FAX: (916) 734-0776                            1. Completed packets - either mail or fax to CME coordinator
 e-mail:                                        2. UCD CME office will enter participants into our database
 gwenn.welsch@ucdmc.ucdavis.edu                 3. Complementary annual transcripts will be mailed out January 2011
 http://cme.ucdavis.edu                         4. Contact Gwenn Welsch if you have any CME questions




        Page 1 of 6                                                                                    (4/2010-GW)
Sponsored by:




                                                          Continuing Medical Education
                                                                    Presents
                                                               “You Asked for It”
                                          Diabetes Update with Case Presentations
                                                 Tuesday, July 20, 2010, 12:00 – 1:00 p.m. (PST)
                                                   Location: Videoconference to remote sites
                                                         Speaker: Pamela T. Prescott, M.D.
                                                    Professor, Endocrine at UC Davis Health System
                                               Course Director: Gibbe Parsons, M.D.
    ________________________________________________________________________________________________
GLOBAL LEARNING OBJECTIVE(S):
At the end of this lecture for participants to be able to: 1. discuss the change in diagnosis of DM using HbA1c and the change
in nomenclature and testing for pre – diabetes; 2. explain the controversies in the update of HbA1c and glucose goals Type 2
DM / TZD and heart disease; 3. describe therapy for Type 2 DM.

SESSION OBJECTIVE - At the completion of this activity the participant should be able to:
1. Recognize the signs and symptoms of dementia due to Alzheimer's disease (AD).
2. Recognize how the signs and symptoms of other dementias differ from AD..

DISCLOSURE:
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for Continuing Medical Education, the University of
California, Davis Health System must ensure balance, independence and objectivity in all CME activities to promote improvements in health care and not
proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational
objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of
educational methods and evaluation of the activity. Course directors, planning committee members, presenters, authors, moderators, panel members and
others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the
subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution
of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring
that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

No financial relationships with commercial interests associated with this CME activity:

ACCREDITATION: The University of California, Davis Health System is accredited by the Accreditation Council for Continuing
Medical Education (ACCME) to provide continuing medical education for physicians.


                                      Learners must sign in to receive CME Credit.


CREDIT DESIGNATION: The University of California, Davis Health System designates this educational activity for a
                                          TM
maximum of 1.0 AMA PRA Category 1 Credit . Physicians should only claim credit commensurate with the extent of their
participation in the activity.

CULTURAL AND LINGUISTIC COMPETENCY: California Assembly Bill 1195 requires continuing medical education activities with patient care components to
include curriculum in the subjects of cultural and linguistic competency. The planners and speakers of this CME activity have been encouraged to address
cultural issues relevant to their topic area. The University of California, Davis Health System, School of Medicine, Office of Continuing Medical Education,
Resources for Physicians also contains many useful cultural and linguistic competency tools including culture guides, language Physicians also contains many
useful cultural and linguistic competency tools including culture guides, language access information and pertinent state and federal laws. You are
encouraged to visit the portal: http://www.ucdmc.ucdavis.edu/cme/resources/AB1195.html




 Page 2 of 6                                                                                                             (4/2010-GW)
                                                                              Live Videoconference Course Code:
                                                                               (official use only) TEL Y 10 07 20



                     No CME credit will be given if site information is not completed.
Tele-site location:  _______________________               Series: “You Asked for It”
Site coordinator:    _______________________               Date: July 20, 2010, 12:00 – 1:00 p.m.
Contact info: Phone: _______________________               e-mail: _______________________

Name                      MD        RN   Other        PIC                             Signature                     1 Hour
(First Last, degree)                                  (Personal Identification Code
                          DO        PA                                                                              Attestation
                                                      EX: JDOEXXXX X= last 4 of
                          Fellow    NP   Students                                                                   Please
                                                      SSN)
                                         Residents                                                                  initial
Example
John Doe, MD                             X Res        JDoe1234                        John Doe, MD                  JD




                                                                  H:\2010_YAFI\April 20 2010\Disclosure-Applebaum_4-20-10.doc
  Page 3 of 6                                                                             (4/2010-GW)
                                                                                   “You Asked for It”
                                                              Diabetes Update with Case Presentations
                                                                       Tuesday, July 20, 2010, 12:00 – 1:00 p.m.
                                                      Speaker: Pamela T. Prescott, M.D., Professor, Endocrine at UC Davis Health System
       RSS EVALUATION
 Office of Continuing Medical Education (OCME)

Live Videoconference – one speaker

Accessed using:       __ Computer            __ Telemedicine Equipment

Location:        UCSF     UCDHS          KAISER         OTHER ________________________________

 If you are a UC Davis Affiliate: (CHECK ONE)                     OCCUPATION:
                                                                   NP    RN    MSW      LCSW
    FACULTY                                                       TECH  CRNA  OPTOMETRIST
    CLINICAL FACULTY                                              PA    RD    Other ___________________
    PCN FACULTY
    VOLUNTEER FACULTY                                             MD or  DO - need specialty
    SOM ALUMNI                                                   Specialty :_____________________________
    OTHER_______________________
                                                                   Medical Student  Resident  Fellow

Speaker:                                                      RATING
                                                                             Excellent       5     4     3      2   1      Poor
This RSS fits the scope of my medical practice                              Agree           5      4    3       2   1     Disagree

I have increased my competence as a result of attending this RSS            Agree           5      4    3       2   1     Disagree

I will apply knowledge and strategy from this RSS in my clinical            Agree           5      4    3       2   1     Disagree
practice

What clinical problems have you been able to solve as a result of attending this RSS?



This presentation was free from commercial bias. If a conflict of           Agree           5      4    3       2   1     Disagree
interest was noted, please specify.


Issues in cultural/linguistic competency were adequately addressed                Yes                          No
in this activity (e.g. difference in prevalence, diagnosis, treatment in
diverse population; linguistic skills; pertinent cultural data).
Resources on cultural and linguistic competency are available on the OCME web site at http://cme.ucdavis.edu under
AB1195. How can we further meet your educational needs in this area?

What are your needs for future educational interventions/activities?


Additional comments:



               PLEASE TURN IN COMPLETED EVALUATION AT THE END OF THE ACTIVITY




 Page 4 of 6                                                                                     (4/2010-GW)
                                                         “YOU ASKED FOR IT”

                          Diabetes Update with Case Presentations
                                                         July 20, 2010
                                                       (noon – 1pm/PST)
                                      RSS - REGULARLY SCHEDULED SERIES 2010 (GRAND ROUNDS)


Two case studies will be presented. These case presentations aim                          FREE CME EVENTS
                                                                                         rd
to clarify the change in diagnosis of DM using HbA1c and the                            3 Tuesday each month
change in nomenclature and testing for pre – diabetes.                                   Live Videoconference
Controversies Update will be discussed regarding HbA1c and                     MUST PRE-REGISTER FOR LIVE CME EVENT
glucose goals Type 2 DM as well as TZD and heart disease. Dr.
Prescott will describe the therapy for Type 2 DM.                        Contact numbers for Live event:
                                                                         For Registration and System Requirements or
                                                                         Problems day of event:
1 hour     UCD Course Codes: TEL Y 10 07 20          (UCTV #18755)       Kalim Simon (916) 734-2327 or cell: (916) 869-4275

Speaker                                                                  CME questions:
Pamela T. Prescott, M.D.                                                 Gwenn Welsch (916) 734-5773 or (916) 734-5390
Professor, Endocrine                                                     Email – gvwelsch@ucdavis.edu
UC Davis Health System
                                                                         Web site for archived “You Asked for It” events:
Objectives                                                               UC CME California Web site
At the completion of this activity the participant should be able to:    New users will need to create an account
1. Discuss the change in diagnosis of DM using HbA1c and the             http://www.cmecalifornia.com/
change in nomenclature and testing for pre – diabetes;
2. Explain the controversies in the update of HbA1c and glucose          ACCREDITATION:
goals Type 2 DM / TZD and heart disease;                                 The University of California, Davis Health System is accredited by the
                                                                         Accreditation Council for Continuing Medical Education (ACCME) to
3. Describe therapy for Type 2 DM.                                       provide continuing medical education for physicians.

                                                                         Physician Credit: The University of California, Davis Health System
                                                                         designates this educational activity for a maximum of 1.0 AMA PRA
Submit Questions: email gvwelsch@ucdavis.edu                             Category 1 Credit™. Physicians should only claim credit
                                                                         commensurate with the extent of their participation in the activity.

                                                                         Psychologist Credit: This educational activity is recognized by the
Topics for 2010                   12-1pm (PST)                           California Board of Psychology as meeting the continuing education
                                                                         requirements toward license renewal for California psychologists.

August 17          Update on Vascular Dementia                           Physician Assistants: The National Commission on Certification of
                         Charles DeCarli, MD                             Physician Assistants (NCCPA) states that AMA PRA Category 1
                                                                         Credits™ are acceptable for continuing medical education
September 21 Mild Cognitive Impairment                                   requirements for recertification.
                         Dan Mungas, PhD
                                                                         Registered Nurse: The California Board of Registered Nursing
                                                                         accepts AMA PRA Category 1 Credits™ toward license renewal. On
October 19         Dementia:                                             the BRN license renewal form, report the number of hours you
                   Community Resources for Caregivers                    attended (up to 1.0 hours of credit) and fill in “CME Category 1” for the
                                                                         provider number.
                         Esther Lara, MSW
                                                                              Consistent with UC Davis Health System policy, faculty are
November 16         New Therapies for Hepatitis C                             expected to disclose any economic or other personal interests that
                         Lorenzo Rossaro, MD, FACP                            creates or may be perceived as creating, a conflict of interest
                                                                              related to the material being presented or discussed. If such a
December 21         Psychotic Disorders                                       conflict exists, the speaker shall demonstrate resolution of these
                                                                              affiliations prior to the presentation. A complete disclosure
                         Glen L. Xiong, MD
                                                                              statement will be displayed at the registration desk, for your review,
                                                                              and a verbal disclosure will be given by the speaker at the
Web site for the 5 UC Schools of Medicine - watch the archived                beginning of the presentation.
videos on http://cmecalifornia.com/


                                                                         Sponsored by: UC Davis Health System
                                                                                       Office of Continuing Medical Education

    Page 5 of 6                                                                                    (4/2010-GW)
                                     UC Davis Health System
                                     Office of Continuing Medical Education (OCME), Grand Rounds Division
                                     3560 Business Drive, Suite 130, Sacramento, CA 95820
                                     (916) 734-5390 phone (916) 734-0776 fax
                                     This form is for Regularly Scheduled Series (Grand Rounds)


                                                    REGISTRATION FORM
                 THIS IS A ONE-TIME REGISTRATION FORM. PLEASE COMPLETE IT AGAIN ONLY IF
               YOUR ADDRESS OR OTHER INFORMATION HAS CHANGED. Send completed form to OCME.

AFFILIATION         UCSF        UCDHS          KAISER         OTHER ________________________________

NAME: ______________________________________ Last 4 digits of your SSN#: _____________
                                                                                                         (For transcript purposes)
MAILING ADDRESS: _____________________________________________________________
                             (address you would like us to mail your complimentary annual transcript)

CITY: ____________________________________________ STATE: _____ ZIP:_____________
PHONE: _______________________ DEPT/DIV: _____________________________________

Email address: ____________________________________________________________________
APPOINTMENT: (CHECK ONE)                      OCCUPATION:
     FACULTY                           CLINICAL FACULTY                    MD or  DO need specialty __________
     VOLUNTEER FACULTY                 SOM ALUMNI                          NP        RN         MSW/LCSW
     PCN FACULTY                       Resident                            TECH      CRNA       OPTOMETRIST
     Medical Student                   OTHER____________                   PA        RD         Other _______
                                                                                                                       Revised 7/28/2011

------------------------------------------------------------------------------------------------------------------------------
                                                                                                    UC Davis Health System
                                                   Office of Continuing Medical Education (OCME), Grand Rounds Division
                                                                     3560 Business Drive, Suite 130, Sacramento, CA 95820
                                                                                   (916) 734-5390 phone (916) 734-0776 fax
                                                                 This form is for Regularly Scheduled Series (Grand Rounds)



                                      REGISTRATION FORM
                 THIS IS A ONE-TIME REGISTRATION FORM. PLEASE COMPLETE IT AGAIN ONLY IF
               YOUR ADDRESS OR OTHER INFORMATION HAS CHANGED. Send completed form to OCME.

AFFILIATION         UCSF        UCDHS          KAISER         OTHER ________________________________

NAME: ______________________________________ Last 4 digits of your SSN#: _____________
                                                                                                         (For transcript purposes)
MAILING ADDRESS: _____________________________________________________________
                             (address you would like us to mail your complimentary annual transcript)

CITY: ____________________________________________ STATE: _____ ZIP:_____________
PHONE: _______________________ DEPT/DIV: _____________________________________

Email address: ____________________________________________________________________
APPOINTMENT: (CHECK ONE)                      OCCUPATION:
     FACULTY                           CLINICAL FACULTY                    MD or  DO need specialty __________
     VOLUNTEER FACULTY                 SOM ALUMNI                          NP        RN         MSW/LCSW
     PCN FACULTY                       Resident                            TECH      CRNA       OPTOMETRIST
     Medical Student                   OTHER____________                   PA        RD         Other _______
                                                                                                                       Revised 7/28/2011

 Page 6 of 6                                                                                   (4/2010-GW)

				
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