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CME Credit Request Form

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Self-Directed CME Activity/Education
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(ie. activity you are requesting CME credit for)

Education Date(s)
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One per line

Course Location/Contact Person
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What are the clinical components of this education?
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What new knowledge will you gain from this education?
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What are the procedural skills you will learn or practice with this education? Focus attention to dealing with low-frequency, high-acuity situations where applicable.
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(ie. patient interaction and communication, patient assessment, history gathering, skill development, patient care, medical math, airway management, pharmacology, etc.)