Continuing Medical Education Reporting Form

INSTRUCTIONS

1. Form to be used for recording CME Credit Hours of attendance at Texas Orthopaedic Association programs/courses.

2. Record each program/course/workshop attended and the number of credit hours. Credit hours are based on hour-for-hour attendance.

CME Accreditation and Credit Designation: Texas Orthopaedic
Association is accredited by the Texas Medical Association to provide
continuing medical education for physicians.

Texas Orthopaedic Association
401 West 15th Street #820
Austin, Texas 78701
(512) 370-1505 • (866) 864-1568 (fax)

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* 1. First Name:

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* 2. Last Name:

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* 3. Suffix (MD, DO, RN, PA or n/a etc)

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* 4. Street Address:

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* 5. City:

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* 6. State:

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* 7. Zip Code:

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* 8. Email Address:

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* 9. If you attended the entire meeting - enter 14.25 below.
(and skip to question #16)

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* 10. If you attended all day Friday only - enter 7.50 below.

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* 11. If you attended all day Saturday only - enter 6.75 below.

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* 12. If you attended just the coding course - enter 6.50 below.
(and skip to question #16)

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* 13. If other - enter the number of hours on Friday you attended below.

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* 14. If other - enter the number of hours on Saturday you attended below.

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* 15. Meeting gave the possibility of 3 hours of Ethics.  If you attended the Friday "Business & Public Policy Symposium" (1.5 hours) or the "Orthopaedic Compensation Models & Benchmarking" (.5 hour) or the Saturday "The Future of Health Care in America" (1 hour) talks - please enter your Ethics hours below:

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* 16. I certify to the best of my knowledge that the above information is correct.

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* 17. Date

Date / Time

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