321610 - Attestation Form: The Brigham Renal Board Review Course

1. Attendance Verification

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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 below questions in order to receive your CME certificate. Your certificate will be emailed to you 2-3 weeks after the survey is completed.

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

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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

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* 2. Your Degree
*THIS QUESTION REQUIRES AN ANSWER

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* 3. Your Email address for Certificate:
*THIS QUESTION REQUIRES AN ANSWER

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* 4. Did you attend the entire course?

Yes (If yes, scroll down to bottom of the page and submit your hours)

No (If no, please indicate which sessions you attended)

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* 5. Please indicate which sessions you attended

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* 6.
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 54.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Course Only: a maximum of 48.0 AMA PRA Category 1 Credits™.

Courses with Lunches & Keynote Dinner: a maximum of 54.0 AMA PRA Category 1 Credits™.
How many credits will you be claiming?
*THIS QUESTION REQUIRES AN ANSWER

	Attended	Did Not Attend
Monday - morning sessions (4.75 CME hrs)	Monday - morning sessions (4.75 CME hrs) Attended	Monday - morning sessions (4.75 CME hrs) Did Not Attend
Monday - afternoon sessions (3.0 CME hrs)	Monday - afternoon sessions (3.0 CME hrs) Attended	Monday - afternoon sessions (3.0 CME hrs) Did Not Attend
Monday- Meet the Professor Lunch (1.0 CME hrs)	Monday- Meet the Professor Lunch (1.0 CME hrs) Attended	Monday- Meet the Professor Lunch (1.0 CME hrs) Did Not Attend
Monday - evening session (1.50 CME hrs)	Monday - evening session (1.50 CME hrs) Attended	Monday - evening session (1.50 CME hrs) Did Not Attend
Tuesday - morning sessions (4.25 CME hrs)	Tuesday - morning sessions (4.25 CME hrs) Attended	Tuesday - morning sessions (4.25 CME hrs) Did Not Attend
Tuesday - afternoon sessions (4.0 CME hrs)	Tuesday - afternoon sessions (4.0 CME hrs) Attended	Tuesday - afternoon sessions (4.0 CME hrs) Did Not Attend
Tuesday - Meet the Professor Lunch (1.0 CME hrs)	Tuesday - Meet the Professor Lunch (1.0 CME hrs) Attended	Tuesday - Meet the Professor Lunch (1.0 CME hrs) Did Not Attend
Tuesday - evening session (1.75 CME hrs)	Tuesday - evening session (1.75 CME hrs) Attended	Tuesday - evening session (1.75 CME hrs) Did Not Attend
Wednesday - morning sessions (4.50 CME hrs)	Wednesday - morning sessions (4.50 CME hrs) Attended	Wednesday - morning sessions (4.50 CME hrs) Did Not Attend
Wednesday - afternoon sessions (5.75 CME hrs)	Wednesday - afternoon sessions (5.75 CME hrs) Attended	Wednesday - afternoon sessions (5.75 CME hrs) Did Not Attend
Wednesday - Meet the Professor Lunch (1.0 CME hrs)	Wednesday - Meet the Professor Lunch (1.0 CME hrs) Attended	Wednesday - Meet the Professor Lunch (1.0 CME hrs) Did Not Attend
Thursday - morning sessions (5.25 CME hrs)	Thursday - morning sessions (5.25 CME hrs) Attended	Thursday - morning sessions (5.25 CME hrs) Did Not Attend
Thursday - afternoon sessions (3.75 CME hrs)	Thursday - afternoon sessions (3.75 CME hrs) Attended	Thursday - afternoon sessions (3.75 CME hrs) Did Not Attend
Thursday - Meet the Professor Lunch (1.0 CME hrs)	Thursday - Meet the Professor Lunch (1.0 CME hrs) Attended	Thursday - Meet the Professor Lunch (1.0 CME hrs) Did Not Attend
Thursday - evening session (1.50 CME hrs)	Thursday - evening session (1.50 CME hrs) Attended	Thursday - evening session (1.50 CME hrs) Did Not Attend
Friday - morning sessions (4.25 CME hrs)	Friday - morning sessions (4.25 CME hrs) Attended	Friday - morning sessions (4.25 CME hrs) Did Not Attend
Friday - afternoon sessions (4.0CME hrs)	Friday - afternoon sessions (4.0CME hrs) Attended	Friday - afternoon sessions (4.0CME hrs) Did Not Attend
Friday - Meet the Professor Lunch (1.0 CME hrs)	Friday - Meet the Professor Lunch (1.0 CME hrs) Attended	Friday - Meet the Professor Lunch (1.0 CME hrs) Did Not Attend

Question Title

* 1. YOUR NAME FOR CERTIFICATE: Please type your name how you would like it to appear on your certificate.*THIS QUESTION REQUIRES AN ANSWER

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* 2. Your Degree*THIS QUESTION REQUIRES AN ANSWER

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* 3. Your Email address for Certificate:*THIS QUESTION REQUIRES AN ANSWER

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* 4. Did you attend the entire course?

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* 5. Please indicate which sessions you attended

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ACCREDITATION

* 1. YOUR NAME FOR CERTIFICATE: Please type your name how you would like it to appear on your certificate.
*THIS QUESTION REQUIRES AN ANSWER

* 2. Your Degree
*THIS QUESTION REQUIRES AN ANSWER

* 3. Your Email address for Certificate:
*THIS QUESTION REQUIRES AN ANSWER