3314207 Attestation - Coaching in Leadership & Healthcare: Theory, Practice & Results 2012

1. Attendance Verification and Certificate Request - Final Page

Page1 / 1

Continuing Education credits are available for physician, psychologist, social workers, licensed mental health counselors and coaches. Please read each question carefully and request the necessary credits.

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

The AMA requires that the number of credits listed on CME certificates be based on the actual credit claimed by each physician. You will need to fill out the below questions in order to receive your CME certificate.

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

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

Question Title

* 2. Your Degree
*THIS QUESTION REQUIRES AN ANSWER

Question Title

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

Question Title

* 4. Select the type(s) of non-physician continuing education credits you require:

	Check all that apply
American Psychological Association (APA) continuing education units (must have attended the entire course)	American Psychological Association (APA) continuing education units (must have attended the entire course) Check all that apply
National Board for Certified Counselors (NBCC) clock hours (please fill our the tracking form in Question 46)	National Board for Certified Counselors (NBCC) clock hours (please fill our the tracking form in Question 46) Check all that apply
Nursing continuing education units:	Nursing continuing education units: Check all that apply
National Association of Social Worker (NASW) contact hours (must have attended the entire course)	National Association of Social Worker (NASW) contact hours (must have attended the entire course) Check all that apply
Board Certified Coach continuing education credits	Board Certified Coach continuing education credits Check all that apply
International Coaching Federation (ICF) credits (please fill out the tracking form in question 45)	International Coaching Federation (ICF) credits (please fill out the tracking form in question 45) Check all that apply

Question Title

* 5. If you are requesting International Coaching Federation Credits, please select which tracks you attended?

	Day One Tracks	Day Two Tracks
Daily tracks	Daily tracks Day One Tracks menu	Daily tracks Day Two Tracks menu

Question Title

* 6. If you are requesting accredited clock hours from the National Board of Certified Counselors (NBCC), please electronically attest to each session you attended:

	Check all that apply
(Day One Sessions: September 27th, 2013) Welcome & Conference Overview - Scott L. Rauch, MD; Carol Kauffman, PhD; Margaret Moore, MBA; Christopher Palmer, MD (45 minutes)	(Day One Sessions: September 27th, 2013) Welcome & Conference Overview - Scott L. Rauch, MD; Carol Kauffman, PhD; Margaret Moore, MBA; Christopher Palmer, MD (45 minutes) Check all that apply
Teaming as Coaching: How People Develop Skills and Capabilities in the Learning Organization - Amy C. Edmondson, PhD (60 minutes)	Teaming as Coaching: How People Develop Skills and Capabilities in the Learning Organization - Amy C. Edmondson, PhD (60 minutes) Check all that apply
Coaching the Addicted Brain - Pamela M. Peeke, MD, MPH, FACP (60 minutes)	Coaching the Addicted Brain - Pamela M. Peeke, MD, MPH, FACP (60 minutes) Check all that apply
Afternoon Track Sessions in Leadership, Healthcare, Positive Psychology or Harvard Medical School. (150 minutes)	Afternoon Track Sessions in Leadership, Healthcare, Positive Psychology or Harvard Medical School. (150 minutes) Check all that apply
Coaching Possibility in a Chaotic World Benjamin Zander and Rosamund Zander, MSS, LICSW (120 minutes)	Coaching Possibility in a Chaotic World Benjamin Zander and Rosamund Zander, MSS, LICSW (120 minutes) Check all that apply
(Day Two Sessions: September 28th, 2013) Discussion Panel and Coaching Theories in Motion: Case Study – Self Determination with Richard M. Ryan, PhD; Positivity with Barbara L. Fredrickson, PhD; Overcoming the Immunity to Change with Robert Kegan, PhD (180 minutes)	(Day Two Sessions: September 28th, 2013) Discussion Panel and Coaching Theories in Motion: Case Study – Self Determination with Richard M. Ryan, PhD; Positivity with Barbara L. Fredrickson, PhD; Overcoming the Immunity to Change with Robert Kegan, PhD (180 minutes) Check all that apply
Afternoon Track Session Leadership, Healthcare, Positive Psychology or Advanced Practice (165 minutes)	Afternoon Track Session Leadership, Healthcare, Positive Psychology or Advanced Practice (165 minutes) Check all that apply
Love 2.0 – Brain Synchrony of Coaching Relationships - Barbara L. Fredrickson, PhD (60 minutes)	Love 2.0 – Brain Synchrony of Coaching Relationships - Barbara L. Fredrickson, PhD (60 minutes) Check all that apply
Stepping Toward the Future, Together - Carol Kauffman, PhD, ABPP, PCC; Margaret Moore, MBA (15 minutes)	Stepping Toward the Future, Together - Carol Kauffman, PhD, ABPP, PCC; Margaret Moore, MBA (15 minutes) Check all that apply
I electronically sign my NBCC tracking form and attest to the accuracy of the educational hours I completed:	I electronically sign my NBCC tracking form and attest to the accuracy of the educational hours I completed: Check all that apply

Question Title

* 7.
ACCREDITATION STATEMENT

The Harvard Medical School is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
Designation Statement:
The Harvard Medical School designates this live activity for a maximum of 13.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Course Credit Breakdown:
If you did not attend every session please use the session listing below to help calculate your total credits/hours to be awarded.

Friday - morning sessions (3.75 CME hrs)

Friday - afternoon sessions (3.50 CME hrs)

Saturday - morning sessions (3.0 CME hrs)

Saturday - afternoon sessions (3.50 CME hrs)

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

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

Question Title

* 2. Your Degree*THIS QUESTION REQUIRES AN ANSWER

Question Title

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

Question Title

* 4. Select the type(s) of non-physician continuing education credits you require:

Question Title

* 5. If you are requesting International Coaching Federation Credits, please select which tracks you attended?

Question Title

* 6. If you are requesting accredited clock hours from the National Board of Certified Counselors (NBCC), please electronically attest to each session you attended:

Question Title

ACCREDITATION STATEMENT

* 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