Required Internet Point-of-Care Learning Activity Verification/Evaluation Form

Directions: 
Use one form for each clinical question researched. Please review the Internet Point-of-Care (iPOC) Learning information on previous page prior to completing the verification/evaluation form.

CME Activity Verification (Required) 

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* 2. Please provide your professional contact information:

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* 3. Physicians, do you give permission for Flagler Hospital CME Department to report your MOC credit to applicable Board?

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* 4. Please provide your Board number for MOC reporting. 

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* 5. Please provide your birth date (only mm/dd required for MOC credit reporting)

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* 6. What is the clinical topic/question:

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* 7. Is the question related to (check all that apply):

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* 8. What did you learn?

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* 9. What resource(s) provided answers for you? (Check and complete all that apply):

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* 10. Please specify the applications/interventions you made as a result of your research (check all that apply):

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* 11. Because of the information obtained through research of clinical question, I avoided possible (check all that apply):

CME Activity Evaluation (required):

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* 12. This activity was fair, balanced, and free from bias?

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* 13. Indicate difficulties finding relevant information (check all that apply):

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* 14. Rate the overall effectiveness of this activity:

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* 15. Check all that apply:

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* 16. This activity resulted in (check all that apply):

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* 17. Comments/Suggestions:

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* 18. Electronic Signature (please type your name and provider ID number):

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* 19. Date:

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ACCREDITATION/CREDIT STATEMENT:  Flagler Hospital is accredited by the Florida Medical Association to provide continuing medical education for physicians.

Flagler Hospital designates this educational activity for a maximum of  (0.5) AMA PRA Category 1 Credit (s) TM. Physicians should claim only the credit commensurate with the extent of their participation the activity.

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Thank you for completing this CME Activity form.  Notification of the CME credit for Internet Point-of-Care (iPOC) will be e-mailed to you and the credit will be added to your transcript and reported to CE Broker for your convenience .  Any questions about iPOC may be directed to Celina at ext. 4409 or e-mail to celina.makowski@flaglerhospital.org or Javeshia at ext. 8071 or email to javeshia.melton@flaglerhospital.org.

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