Use as a guide only. Fill in your own information. Delete instructions in parentheses before submitting.
TITLE OF CONFERENCE:
DATES (INCLUDE DAYS OF THE WEEK)
SPONSORED BY: (this is always The University of Iowa Roy J. and Lucille A. Carver College of Medicine
plus whatever departments and divisions are involved. Not the group who may be providing commercial
support which is listed elsewhere in this brochure.)
LOCATION:
INTENDED AUDIENCE
PURPOSE
EDUCATIONAL OBJECTIVES:
Upon completion of this conference, the participant should be able to:

Identify……..

Utilize………

Describe………

Discuss……….

Explain……………….

Review………………….

Evaluate………….

Apply……………
REGISTRATION FEES (EXAMPLE PROVIDED – PLEASE FILL IN YOUR OWN INFORMATION)
The fee is $xxx for physicians and $xxx for nurses and allied health care professionals. U of I full-time faculty
physicians (tenure- or new clinical-track) and residents in training will be allowed to attend free of charge.
Clinical-appointment faculty members of The University of Iowa College of Medicine and retired or emeritus
physicians may register for a fee of $xx Medical students, with identification, will be admitted to the
conference free of charge (lunch extra). All fees include registration, instruction and educational materials,
CME and CEU recording, continental breakfast, refreshment breaks and lunches.
While registration is open until the start of the meeting, we encourage early registration to enable us to provide
the best possible service to participants. A $25 fee will be charged for canceled registrations.
Use as a guide only. Fill in your own information. Delete instructions in parentheses before submitting.
SPECIAL EVENTS (IF APPLICABLE)
DETAILED CONFERENCE LOCATION
PARKING
HOUSING (EXAMPLE)
A limited number of rooms have been reserved at the Sheraton Iowa City Hotel, Iowa City, IA 52240
(Downtown Iowa City). Room rates are $xxx excluding taxes. Registrants are responsible for making their own
housing arrangements and may do so by contacting the hotel reservation operator at 319/337-4058. When
making hotel room reservations, be sure to state you are attending the “xxx Conference” in order to receive the
special conference room rates. Sheraton Iowa City Hotel amenities include convenient downtown location
within walking distance to shopping and restaurants; an indoor heated pool, whirlpool, and sauna; workout
facility and game room; complimentary ramp parking; in-room Internet access; complimentary continental
breakfast; and in-room hair dryer and iron with ironing board.
CONTINUING EDUCATION CREDIT – WE WILL FILL IN.
The University of Iowa Roy J. and Lucille A. Carver College of Medicine is accredited by the Accreditation
Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Physicians: The University of Iowa Carver College of Medicine designates this educational activity for a
maximum of x.x AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the
extent of their participation in the activity.
Nurses: This program is offered in cooperation with the University of Iowa College of Nursing, an Iowa Board
of Nursing approved provider, number 1. Participants will receive .xx Continuing Education Units (CEUs) or
x.x contact hours. Program number xx xxx xx has been assigned.
Determination of educational content for this program and the selection of speakers are responsibilities of the
program director. Firms providing financial support did not have input in these areas.
DISCLOSURE POLICY: Everyone in a position to control the content of this educational activity will
disclose to the CME provider and to attendees all relevant financial relationships with any commercial interest.
EMERGENCY CALLS
You can be reached during conference hours for emergency calls at (please provide a phone number.) Please
have the caller identify the conference you are attending.
AIR TRAVEL (IF APPLICABLE)
Iowa City is served by Allegiant Air, American Airlines, Delta, Northwest Airlines, and United through the Eastern Iowa Airport
(Cedar Rapids) which is 30 minutes from Iowa City. The phone number of the Eastern Iowa Airport is (319) 362-8336. Commercial
limousine or taxi service is available from the airport to Iowa City. Airport shuttles may be reserved from Cedar Rapids to Iowa City
upon arrival at the Eastern Iowa Airport, or you may reserve a shuttle to Iowa City in advance by calling (800) 383-2219 or (800) 725-
Use as a guide only. Fill in your own information. Delete instructions in parentheses before submitting.
8460. The Iowa City Municipal Airport is available for use by private aircraft.
DISABILITY STATEMENT
The University of Iowa prohibits discrimination in employment, educational programs, and activities on the basis of race, national
origin, color, creed, religion, sex, age, disability, veteran status, sexual orientation, gender identity, or associational preference. The
University also affirms its commitment to providing equal opportunities and equal access to University facilities. For additional
information contact the Office of Equal Opportunity and Diversity, (319) 335-0705.
Individuals with disabilities are encouraged to attend all University of Iowa sponsored events. If you are a person with a disability who
requires an accommodation in order to participate in this program, please contact the Continuing Medical Education Division in
advance at 319/335-8599.
FOR FURTHER INFORMATION, PLEASE CONTACT:
Continuing Medical Education Division
Roy J. and Lucille A. Carver
College of Medicine
University of Iowa Carver College of Medicine
100 CMAB
Iowa City IA 52242-1101
Phone: 319/335-8599
FAX: 319/335-8327
OR WHOEVER IS TAKING YOUR REGISTRATIONS
PROGRAM AGENDA
(List all activities beginning with times, including registration, lectures, meals, breaks, receptions, banquets,
entertainment, etc.) Provide speakers’ full names and titles.
PROGRAM FACULTY
Guest Faculty (Outside the UI) List names of all speakers, degrees, titles, institutional affiliations, cities.
College of Medicine Faculty List names of all speakers as well as planning committee, degrees, titles,
institutional affiliations, cities.
REGISTRATION FORM
Use as a guide only. Fill in your own information. Delete instructions in parentheses before submitting.
Please print clearly.
Name ______________________________________________________
Address
Degree
City
State/ZIP
Specialty
Phone
Email
________________________________________
Company or Business Name _________________________________________
Check here if you do NOT want to be included in a class list distributed to course
attendees _____
For Office Use Only PN xx-xxx-xx
Category 1 AMA credit earned
CEUs
Date
REGISTRATION FEES (Include all categories of fees, tickets for activities, meals, receptions, etc.
xxxxxxxxxxxxx
$ ________
xxxxxxxxxxxxxxxxxxx
$ ________
xxxxxxxxxxxxxxxxxx
$ ________
METHOD OF PAYMENT
I enclose a check made payable to
The University of Iowa in the amount of
$
Please charge my:
Cardholder name (please print) _____________________________
Account #
Signature
Expiration date _____
3-digit security code on back_____________
Four ways to register: Mail, Phone, Fax or Online
Use as a guide only. Fill in your own information. Delete instructions in parentheses before submitting.
Mail:
University of Iowa Carver College of Medicine
Continuing Medical Education Division
100 Medicine Administration Bldg.
Iowa City, IA 52242-1101
Phone: Telephone: 319/335-8599
FAX: 319/335-8327
Online: www.medicine.uiowa.edu/cme and click on Upcoming Conferences
For additional information on this program and other upcoming CME events at the UI Carver College of
Medicine, please visit http://www.medicine.uiowa.edu/cme/.
Use as a guide only. Fill in your own information. Delete instructions in parentheses before submitting.
MAILER
University of Iowa Carver College of Medicine (logo)
Continuing Medical Education Division
100 Medicine Admin. Bldg.
Iowa City IA 52242-1101
Nonprofit Organization
US Postage
PAID
Permit No. 45
Iowa City, IA
Title of conference
Dates of conference
Location of Conference
The University of Iowa prohibits discrimination in employment, educational programs, and activities on the basis of race, national origin, color, creed,
religion, sex, age, disability, veteran status, sexual orientation, gender identity, or associational preference. The University also affirms its commitment to
providing equal opportunities and equal access to University facilities. For additional information contact the Office of Equal Opportunity and Diversity,
(319) 335-0705.
Individuals with disabilities are encouraged to attend all University of Iowa sponsored events. If you are a person with a disability who requires an
accommodation in order to participate in this program, please contact the Continuing Medical Education Division in advance at 319/335-8599.