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Continuing Medical Education Activity Evaluation Form
Annals of Allergy, Asthma, & Immunology Continuing Medical Education Activity Evaluation Form A. Instructions: 1. Read the CME article in this issue carefully and complete the activity evaluation by completing the form. 2. To receive CME credit, complete the form below and submit it to the ACAAI office within one year after receipt of the Annals. B. Quiz and Evaluation: 1. Circle answer: Q1. a b c d e Q2. a b c d e Q3. a b c d e Q4. a b c d e Q5. a b c d e 2. Circle “Yes” or “No” Yes No A. The article met its learning objectives. Yes No B. I verified some important information. Yes No C. This activity will influence how I practice medicine. 3. Rate the overall effectiveness of the CME activity: 5 (very effective)
4
3
2
1 (not at all effective)
C. Statement of completion: I attest to having completed the CME activity. (Sign here) (Date) D. Please indicate the issue and volume this form represents: Year Month
Volume
E. 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. Participants will be provided with an annual report on the number of CME credits earned each year. Checks are to be in U.S. funds payable to the American College of Allergy, Asthma, & Immunology. F. Participant information: Name
(Please print)
Address City
State
Zip
Return completed form to: Attn: CME Coordinator The American College of Allergy, Asthma, and Immunology 85 West Algonquin Rd, Suite 550 Arlington Heights, IL 60005 Fax 1-847-427-1294
16
ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY
Annals of Allergy, Asthma, & Immunology CME – Needs Assessment Part of the mission of The American College of Allergy, Asthma, and Immunology is to better serve the CME educational needs of our membership and readership. We ask you to identify the areas of CME education that you feel need to be addressed. We will collate the subject needs yearly and plan to have certain of these educational subjects published in the Annals. Please list subjects that reflect your educational needs and interests and fax to: ACAAI at 847-427-1294
Date Name (optional)
VOLUME 88, JANUARY, 2002
17
4
3
2
1 (not at all effective)
C. Statement of completion: I attest to having completed the CME activity. (Sign here) (Date) D. Please indicate the issue and volume this form represents: Year Month
Volume
E. 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. Participants will be provided with an annual report on the number of CME credits earned each year. Checks are to be in U.S. funds payable to the American College of Allergy, Asthma, & Immunology. F. Participant information: Name
(Please print)
Address City
State
Zip
Return completed form to: Attn: CME Coordinator The American College of Allergy, Asthma, and Immunology 85 West Algonquin Rd, Suite 550 Arlington Heights, IL 60005 Fax 1-847-427-1294
16
ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY
Annals of Allergy, Asthma, & Immunology CME – Needs Assessment Part of the mission of The American College of Allergy, Asthma, and Immunology is to better serve the CME educational needs of our membership and readership. We ask you to identify the areas of CME education that you feel need to be addressed. We will collate the subject needs yearly and plan to have certain of these educational subjects published in the Annals. Please list subjects that reflect your educational needs and interests and fax to: ACAAI at 847-427-1294
Date Name (optional)
VOLUME 88, JANUARY, 2002
17