Name of Program
Date
CME Verification Form
Ohio University Heritage College of Osteopathic Medicine (OU-HCOM) is accredited by the
American Osteopathic Association as a CME Sponsor. This program will be submitted for
X credit of AOA Category X CME credit.
You should request credit for only those hours actually attended.
No credit will be given if this form is not completed and returned at the end of the
program. Physician names and AOA numbers of attendees of this program will be
directly submitted to the AOA for CME credit. Certificate will be e-mailed to those
who provide an email address. Please Print CLEARLY.
Number of Hours Requested for Attending:
AOA Number (required):
Signature:
Print Name:
e-mail: