LEO-Certificate-and-Credit-Claim-Form

LAW ENFORCEMENT OFFICERS WILL KEEP THIS PORTION FOR THEIR RECORDS 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 This live activity was designated for a maximum of 15.00 AMA PRA Category Credits™ I participated in hours (Please fill in the # of credits you are claiming from the Credit Claim Form for Attestation of Participation.) CoCODirector, UAMS Office of Continuing Education The University of Arkansas for Medical Sciences Office of Continuing Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians A transcript of all participation in UAMS accredited CE activities, is available from the Office of Continuing Education website 24/7 To obtain a transcript go to ce.uams.edu Transcripts for this activity will be available 68 weeks after the activity Please direct questions to: UAMS Office of Continuing Education, 4301 W Markham #525, Little Rock, AR 72205 Phone: 501-661-7962 or fax: 501-661-7968 ce.uams.edu LAW ENFORCEMENT OFFICER Certificate 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- Law Enforcement Officer Cell Phone # - - (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