MCLE ATTENDANCE VERIFICATION FORM

MARKETING DEPARTMENT – RECORDED FORMAT WEBINAR

Program: / Patient Safety Organizations: What Every Health Care Provider Needs to Know (Part 1 of 3)
PSO 101: Overview of Patient Safety Act
Formats: / Live Webinar; Recorded
Presenters: / Michael R. Callahan (Partner/Corporate Department-Health Care Practice Area/Katten Muchin Rosenman LLP-Chicago); Guest Speakers: Ellen Flynn (AVP, Patient Safety and Accreditation Programs-UHC Safety Intelligence PSO) and Stephen Pavkovic (Senior Director of Patient Safety/Vizient)
Date/Time: / January 12, 2016 / 12:00 p.m.-1:30 p.m. CST
Location: / Katten Muchin Rosenman LLP – Chicago (Live Broadcast Location)
Katten Muchin Rosenman LLP is an accredited provider of continuing legal education (CLE) in California, Illinois and New York only. We are not accredited to issue credit for any other jurisdictions and/or professional accreditations.
The above-referenced program has been APPROVED for continuing legal education credit by the
·  Illinois MCLE Board and the State Bar of California for 1.5 General credits
·  New York State Continuing Legal Education Board for 1.5 CLE credits in Professional Practice for NY experienced attorneys only
TO REQUEST CALIFORNIA, ILLINOIS, AND/OR NEW YORK CLE CREDIT: Submit your completed MCLE Attendance Verification Form to within 24 hours of viewing the program. A MCLE Program Evaluation Request and Certificate of Attendance (IL/CA/NY only) will be sent electronically within 60-90 days receipt of your completed verification. New York attorneys must retain a copy of this verification with their NY CLE Certificate of Attendance.
DUE TO NEW MCLE COURSE/ATTENDANCE FEE REPORTING RULES IMPLEMENTED BY THE
ILLINOIS MCLE BOARD ON JANUARY 1, 2016, CLE REQUESTS REVCEIVED
AFTER THE 27TH DAY OF THE MONTH CANNOT BE ACCOMMODATED.
Check applicable
CLE jurisdiction(s): / I participated in the above program in its entirety and am eligible to claim CLE credit for the following jurisdiction(s):
(Credit will be issued for
these jurisdictions only.) / _____ California
_____ Illinois / _____ New York
(experienced attorneys only)
Check applicable
participation format: / _____ Live Webinar
_____ Live Teleconference
_____ Live Videoconference / Participant Location:
______
(city/state)
Dated Viewed/Listened: / ______, 2016 / ______, 2017
Indicate the in/out times of your participation: / Time In: ______a.m. / p.m. _____CST / _____EST / _____PST
Time Out: ______a.m. / p.m. _____CST / _____EST / _____PST
Enter the CLE Course Verification Code announced during the program: / ______ / If the verification code and above in/out times are omitted, Katten Muchin Rosenman LLP cannot award CLE credit per state MCLE rules and regulations.
Print name legibly:
Signature:
Date Submitted: / ______, 2016 / ______, 2017
E-mail address (print legibly):
Bar Information: / No. ______
(Credit will be issued for
IL/CA/NY only.) / State(s) licensed: ______ / Check here if newly-admitted: ___

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