2021 Scholarly Works Virtual Summit CME Reporting form

Please fill out this survey entirely and submit one for each presentation that you review today. Thank you for volunteering. Once you submit the survey, it will restart at the beginning so that you can be ready to score the next presentation in your review session.

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* 1. Your Name

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* 2. MD or DO?

Other degrees to include (ex. MPH, FAAFP)

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* 3. Email Address

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* 4. Presentations that you viewed

#1 at 9:00 am Dr. Miller

#2 at 9:20 am Dr. Kovtsun

#3 at 9:40 am - Dr. Hinojosa Soria

#4 at 10:00 am - Dr. Hertenstein Perez

#5 at 10:20 am - Dr. Kabir

#6 at 10:40 am - Dr. Scafaru

#7 at 11:20 am - Dr. Hereha

#8 at 11:40 am - Dr. Laton

#9 at 12:00 - Dr. Harvey

#10 at 12:20 pm - Dr. Cheng

#11 at 12:40 pm - Dr. Tariq

#13 at 2:00pm - Dr. Baran

#14 at 2:20 - Dr. Ghanayem Kubilius

#15 at 2:40 pm Dr. Reinhart

#17 at 3:20 pm - Dr. Yones

#18 at 3:40 pm - Dr. Harvey 2nd presentation

#19 at 4:20pm - Dr. Hall

#20 at 4:40 pm - Dr. Dillard

#21 at 5:00 pm - Dr. Vasquez

#22 at 5:20pm - Dr. Kim

#23 at 5:40pm - Dr. Toledo

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* 5. Total number of presentations viewed

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* 6. Are you claiming CME credit?

Yes

No, please send me a certificate of participation only

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* 7. Total number of credits claimed (at .25 credits per presentation)

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* 8. Were the presentations you reviewed free from commercial bias

Yes, all of them

Not all of them

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* 1. Your Name

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* 2. MD or DO?

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* 3. Email Address

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* 4. Presentations that you viewed

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* 5. Total number of presentations viewed

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* 6. Are you claiming CME credit?

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* 7. Total number of credits claimed (at .25 credits per presentation)

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* 8. Were the presentations you reviewed free from commercial bias

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* 9. If you answered "Not all of them" above, please specify which presentations (# and presenter or title) concerned you and why?