Continuing Education Credit Request Form

Continuing Education Credit Request form

Activity Title

Monthname ##, 2018 • Cityname, ST

INSTRUCTIONS: Update the red text above and below to reflect the information for your CME activity. Add/delete rows in the checkbox table below as necessary in order to account for all CME sessions at your CME activity. Change all text to black once it has been updated, and then delete these INSTRUCTIONS sentences.

To receive CME/AMA creditsfor participation in this continuing medical education activity, complete the form below. Your certificate will be mailed or emailed to you.

Continuing Education for Non-Physicians:Certificates of attendance can be issued to non-physicians for attending this continuing medical education activity. The University of Tennessee designates CEU’s using the national standard that 1 live hour of educational instruction is awarded .1 CEU.

Please check all sessions attended:

TIME: / LENGTH: / TITLE & SPEAKER:
□ / 8:10-9:00 am / 50 mins / Presentation Title – Firstname Lastname, DE
□ / 9:00-9:50 am / 50 mins / Presentation Title – Firstname Lastname, DE
□ / 10:10-11:00 am / 50 mins / Presentation Title – Firstname Lastname, DE
□ / 11:00-11:50 am / 50 mins / Presentation Title – Firstname Lastname, DE

Total minutesAttended: ______/200 minutes total

LEARNER INFORMATION

PLEASE PRINTCLEARLY

______

First Name Last Name Degree

______

Address City State Zip

______/____/______

National Provider ID Tennessee License # (if licensed in TN) Date of Birth

ATTESTATION

By signing below, I attest that I attended the sessions indicated above.

______

Signature

SUBMISSION TO THE TBME & ACCME
The UT College of Medicine is participating in a pilot project between the ACCME and the Tennessee Board of Medical Examiners (TBME) to allow the TBME to automatically verify licensees’ participation in a CME activity with minimal action from the licensees, and we will automatically share your participation data with the ACCME and TBME unless you indicate below that you do not want us to.
□ Check here if you do not want us to share your participation data for this CME activity with the ACCME & TBME to allow the TBME to automatically confirm your participation.