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3214207 Attestation Form - Coaching in Leadership & Healthcare: Theory, Practice & Results 2012

4. Attendance Verification

The AMA requires that the number of credits listed on CME certificates be based on the actual credit claimed by each physician. Please complete the questions below in order to receive your CME certificate. Your certificate will be emailed to you with the next 2-3 weeks.

* Questions with an asterisk are required before evaluation can be submitted.

Thank you and if you have any questions, please let us know.

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1.YOUR NAME FOR CERTIFICATE: Please type your name how you would like it to appear on your certificate.
*THIS QUESTION REQUIRES AN ANSWER(Required.)
2.Your Degree
*THIS QUESTION REQUIRES AN ANSWER(Required.)
3.Your Email address for Certificate:
*THIS QUESTION REQUIRES AN ANSWER(Required.)
4.Select the type(s) of non-physician continuing education credits you require:

Check all that apply
APA credits for Psychologist (must have attended the entire course)
NBCC credits for counselors and licensed mental health professionals (please fill out the tracking form below).
RN credits for Nurses (must have attended the entire course)
SW credits for Social Works (must have attended the entire course; please enter your license number below)
Certified Coach Credits (12.75 for entire course)
International Coaching Federation credits (please fill out the tracking form below)
5.If you are requesting social worker continuing education credits, please enter your social worker license number.
6.If you are requesting International Coaching Federation Credits, please select which tracks you attended?
Check all that apply
(Day One) Track One
Track Two
Track Three
Track Four
(Day Two) Track One
Track Two
Track Three
Track Four
7.If you are requesting credits from the NBCC for counselors or licensed mental health professional, please complete the NBCC tracking form below:

Check all that apply
(Day 1) Welcome & Conference Overview - Carol Kauffman, PhD; Margaret Moore, MBA; Christopher Palmer, MD
Emotional Intelligence: Active Ingredients in Coaching - Dan Goleman, PhD
Mindsight in Health & Creative Leadership - Dan Siegel, MD
Keynote Panel, Q&A - Dan Siegel, MD; Dan Goleman, PhD
Leadership: Track 1: Coaching Four Capabilities in Leaders - Deborah Ancona, PhD
Healthcare: Track 2: Coaching Research in Healthcare - Ruth Wolever, PhD; Gerald Jerome, Ph.D
Positive Psychology: Track 3: VIA & Virtuous Leaders: Character, Strategy, & Influence in the 21st Century - Dick Kilburg, PhD; Neal Mayerson, PhD; Donna Mayerson, MEd, PhD
Advanced Practice: Track 4: Changing Mindsets: Strategies for Developing Motivation & Resilience-Robert Brooks, PhD
Character & Competence -Scott Snook, PhD
(Day 2) Leadership in an Age of Uncertainty: What Do I Do Now? - Deborah Ancona, PhD
The Road to Health: From Less Travelled, to Lesser Resistance - David Katz, MD
Leadership: Track 1: Overcoming the Immunity to Change - Robert Kegan, PhD
Healthcare: Track 2: Obesity Coaching in Action: Core Skills and Practice - David Katz, MD; Margaret Moore, M.B.A
Positive Psychology: Track 3: Mapping Science to the Art of Co-Active Coaching - Karen Kimsey-House, MFA; Carol Kauffman, PhD
Harvard Medical School: Track 4: What's New for Coaches from Harvard Medical School
Helen Riess, MD, Shelley Carson, PhD - Jeff Szymanski, PhD, Lilian Cheung, PhD
Life at the Frontier: Courageous Conversations between Competence, Care and Compassion- David Whyte, PhD
Stepping Toward the Future, Together - Carol Kauffman, PhD; Margaret Moore, MBA
8.Did you attend the entire course?(Required.)
9.Please indicate which sessions you attended
Attended
Did Not Attend
Friday - morning sessions (3.25 CME hrs)
Friday - afternoon sessions (4.25 CME hrs)
Saturday - morning sessions (3.50 CME hrs)
Saturday - afternoon sessions (3.25 CME hrs)
10.

ACCREDITATION

The Harvard Medical School is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Harvard Medical School designates this live activity for a maximum of 14.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

By submitting your evaluation and certificate request form, you are attesting to an electronic sign-out for this course How many credits will you be claiming?

*THIS QUESTION REQUIRES AN ANSWER

(Required.)