CME Evaluation Form

Annals of Allergy, Asthma & Immunology Continuing Medical Education Activity Evaluation Form The American College of Allergy, Asthma and Immunology (ACAAI) designates this Journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. A. Instructions to obtain AMA PRA Category 1 CME CreditTM: 1. Read the CME article in this issue carefully and complete the activity by answering the self-assessment test questions, completing the evaluation, and claiming credit on the form below. 2. To receive CME credit, submit the completed form to the ACAAI office prior to the expiration date as posted on the article. (Physicians will receive a certificate of credit; other health professionals will receive a certificate of participation.) B. Quiz and Evaluation: 1. Circle answer: Q1. a b c d e Q2. a b c d e 2. Circle Yes or No Yes No Yes No Yes No Yes No

A. B. C. D.

Q3. Q4.

a a

b b

c c

d d

e e

Q5.

a

b

c

d

e

Met learning objectives. Learned something new or verified important information. This activity was free from bias. If not free from bias, please explain: _______________________ This activity will influence or change how I practice medicine.

3. Rate the overall effectiveness of the CME activity: 5 (very effective) 4

3

2

1 (not at all effective)

4. What will you do differently in your practice as a result of this acitivity?

5. If applicable, what barriers may prevent you from making planned changes to your practice?

C. I, certify that I have met the criteria for CME credit by studying the designated materials, by responding to the self-assessment questions, by reviewing those parts of the article dealing with any question(s) answered incorrectly, and by referring to the supplemental materials listed in the references. (Sign here) (Date) D. Please indicate the issue and volume this form represents: E. Credits claimed: increments: .25, .50, .75, or 1.0)

Year

Month

Volume

TM

Maximum of 1 AMA PRA Category 1 Credit . (Credits may be claimed in the following

F. Participant information: Name (Please print) Address

City ACAAI Member ID#

472

State

Zip Check if Non-member

ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY

G. Charges Recording of Annals CME credits is provided to members of the American College of Allergy, Asthma & Immunology at a cost of $25 per year. Nonmembers will be charged $50 per year. This cost will cover processing of forms and reporting of CME credits earned during the year. Checks are to be in U.S. funds payable to the American College of Allergy, Asthma & Immunology.

Annals of Allergy, Asthma & Immunology H. Based on educational needs, please provide healthcare or professional practice gaps that should be addressed in future educational activities and that may be applicable to your practice:

Date Return completed form to: Attn: CME Administrator; The American College of Allergy, Asthma and Immunology; 85 West Algonquin Rd, Suite 550; Arlington Heights, IL 60005 Fax 1-847-427-1294

VOLUME 107, DECEMBER, 2011

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