The Oklahoma State Medical Association, OU Medicine,

Oklahoma Pediatric Wellness Center and

Center for the Advancement of Wellness, OSDH

“Pediatric Obesity Management in Primary Care”

Ongoing Webinar Monthly Training for 2015

June 9, 2015

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Name:______

Address:______City: ______State:______Zip:______

Phone:______Fax:______

Please indicate status: MD______DO______Specialty______Other______

To officially receive AMA PRA Category1 CreditsÔ, please complete this entire form.

Faculty/CME Planning Committee/Reviewer Disclosures: Have no relevant financial relationships to disclose.

Commercial Support: There will be no Commercial Support.

Webinar #6 – Tuesday, June 9, 2015

“Overview of Obesity Co-morbidities”- Ashley Weedn, MD

Please rate each question accordingly: Excellent 5 Good 4 Avg 3 Fair 2 Poor 1

1)Measurement of topic knowledge prior to presentation: 5 4 3 2 1

2)The program will impact me or my practice: 5 4 3 2 1

3) The objectives and disclosure were met: 5 4 3 2 1

4)The program was free of commercial bias: 5 4 3 2 1

5)Speaker was knowledgeable and

responded to the questions with detailed information: 5 4 3 2 1

6)Measurement of my knowledge of this topic

following the presentation: 5 4 3 2 1

7)Due to this presentation, improvements I plan to make:

8)Barriers that prevent change in practice:

Accreditation Statement

This activity has been planned and implemented in accordance with the Accreditation requirements and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Oklahoma State Medical Association and the Oklahoma Pediatric Wellness Center. The Oklahoma State Medical Association (OSMA) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians.

The OSMA designates this live activity for a maximum of 1 AMA PRA Category 1 CreditsÔ. Physicians should claim only the credit commensurate with the extent of their participation in the activity. ______

The OSMA CME Manager has reviewed all speaker information and has resolved all conflicts of interest if applicable.

Please email completed form to Melissa Johnson at or fax to 405-601-9575. Please keep a copy for your records.

Participant signature:______Date:______