Nurse-Certificate-and-Credit-Claim-Form

University of Arkansas for Medical Sciences Office of Continuing Education certifies that participated in the live activity entitled ICARE: Improving Critical and Acute Care through Regional Education May 3-5, 2017 The Chancellor Hotel, Fayetteville, AR And is awarded _ Contact Hours (Please fill in the # of credits you are claiming from the Attestation of Participation.) Office of Continuing Education, University of Arkansas for Medical Sciences is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation UAMS Office of Continuing Education 4301 W Markham #525 Little Rock, AR 72205 In order to receive CME credit, this page MUST be filled out completely, and returned to the Registration Desk or UAMS CE Office CREDIT CLAIM FORM FOR ATTESTATION OF PARTICIPATION Please fill in the hours that you are claiming in the ‘# Credits Attended column’, indicate Total Credits Claimed, and sign the attestation below ICARE: Improving Critical and Acute Care Through Regional Education May 3-5, 2017 The Chancellor Hotel, Fayetteville, AR TIME FRAME May 3rd th May th May CREDITS AVAILABLE SESSION NAME 0900 – 1100 Active Shooter Response Tabletop Exercise 2.00 1300 – 1430 1.50 1445 – 1545 Concurrent Sessions A, B, or C Group Reports: Future Directions for Statewide Efforts, Debriefing of Active Shooter Tabletop Exercise 0800 – 0830 Introduction to the ICARE Concept 0.50 0830 – 0930 Rapid Fire Didactics – Session 1.00 0930 – 1000 Q&A Panel on Rapid Fire Didactics – Session 0.50 1030 – 1130 Rapid Fire Didactics – Session 1.00 1130 – 1200 Q&A Panel on Rapid Fire Didactics – Session 0.50 1300 – 1345 Poster Highlights Session 0.75 1345 – 1545 Concurrent Sessions A, B, or C 1.75 1615 – 1715 Summation of Breakouts and Wrap-Up 1.00 0800 – 0845 Reflections on Current Work and Looking Ahead 0.75 0845 – 1000 Concurrent Sessions A or B 1.25 1030 – 1130 EMS Decon in a Disaster 1.00 1130 – 1200 Debriefing and Evaluations 0.50 # CREDITS ATTENDED 1.00 Day = 4.50 Day = 7.00 Day = 3.50 TOTAL=15.00 (Remember to enter credits claimed on first page of this form.) TOTAL CREDITS CLAIMED Last of SSN xxx-xx- Physician APRN/NP Cell Phone # RN/LPN/BSN - PhD or EdD - (for identification purposes only) Other: Email LEGIBLY PRINTED Name _ Affiliation Mailing Address _ City/State _Zipcode _ I attest that I attended the hours indicated above Signature