CME/CE REQUEST FORM: STEP 1 OF 2
Dear Participant in 2015 National Rx Drug Abuse Summit:
This form is for all conference participants wishing to earn CME/CE contact hours. This form MUST be
completed, signed and returned to clackey@twc.com or 606.677.6166 (fax)
The CME/CE process has two steps:
Step 1:
 Attend/participate in the educational sessions and review all course materials.
 Complete and sign this CME/CE Request Form and send it to clackey@twc.com or 606.677.6166
(fax).
Step 2:
 Complete CME/CE electronic evaluation forms at www.cmeuniversity.com by 11:59 p.m. ET on May
31, 2015. PLEASE NOTE: THE CME/CE PROCESS IS NOT COMPLETE UNTIL YOU SUBMIT
THE(SE) ELECTRONIC FORM(S).
 You must have the correct Course ID. The course IDs are listed on the “CME/CE ELECTRONIC
EVALUATION INSTRUCTIONS: STEP 2 OF 2” sheet (click here).
 Once you complete your evaluation form for the session(s) you are claiming for credit, then your
certificate will be made available immediately. (Please note: depending on the type of credit you are
claiming, you may be required to complete an evaluation form for each individual session you
attended.) For Pharmacists, you will not receive a certificate – you must click on the button “Submit to
CPE Monitor” and your transcript information will be available at www.mycpemonitor.net immediately.
 The only exception is for members of the Georgia Bar, who do not need to do Step 2. However, nonGeorgia Bar members must do Step 2 if they want a certificate in order to request CLE in their state.
SECTION I. Please print or write legibly:
GA Bar # (For Georgia Bar members only) _____________________________________________________
Name _____________________________________________ Credentials ___________________________
Title _______________________________ Organization _________________________________________
Address ________________________________________________________________________________
City _______________________________ State __________________ Zip __________________________
Phone ____________________________ E-Mail ________________________________________________
SECTION II. I wish to earn CME/CE for which profession:
 Physician
(ACCME)
Maximum hours 10.5
 Family Physician (AAFP)
Maximum hours 10.5
 Psychologist
(APA)
Maximum hours 10.5
 Pharmacist
(ACPE)
Maximum hours 10.25
 Nurse
(ANCC)
Maximum hours 10
 Social Worker
(NASW)
Maximum hours 10
 Certified Counselor (NBCC)
Maximum hours 10
 Georgia Bar
(CLE)
Maximum hours 13.8
 Georgia POST Council
Maximum hours 13
 Addiction Professional (NAADAC) Maximum hours 10
 Prevention Professional
Maximum hours 10
 Health Educators (NCHES)
Maximum hours 14
Total Hours Claimed __________
Signature _______________________________________________________________________________
OVER
SECTION III. Please check the box for each session you attended:
Monday, April 6, 2015 — Concurrent Block (2:00 pm – 3:00 pm)
3 hours
 HIDTA in the 21st Century: Issues and Opportunities
 Latest Research on Intrauterine Drug Exposure and Neonatal Abstinence Syndrome
TOTAL DAY 1
Tuesday, April 7, 2015 — Concurrent Block 1 (11:15 am – 12:30 pm)




1.25 hours
Clinical Track: US and Canadian Prescriber Attitudes and Education
Education & Advocacy Track: Planning and Best Practices for Community Responses
PDMP Track: Improving Utilization of PDMPs
Treatment Track: Evolution of Diagnosis and Treatment Options
Tuesday, April 7, 2015 — Concurrent Block 2 (12:30 pm – 1:45 pm)




_________
1.25 hours
Law Enforcement Track: DEA Update: Diversion Trends and Proper Disposal
Pharmacy Track: Pharmacists Working with Local Coalitions and PDMPs
Third-Party Payer Track: Legislative and Medication Trends Impacting Third Party Payers
Trending Topics Track: Data-Driven Trends
Tuesday, April 7, 2015 — Concurrent Block 3 (2:00 pm – 3:15 pm)
1.25 hours
 Clinical Track: FDA on Decreasing Opioid Risks and VA on Exploring Non-Opioid Options
 Education & Advocacy Track: Prevention Campaigns Targeting Young Adults
 Law Enforcement: Enhancing the Role of Law Enforcement: Education & Awareness & Naloxone
Programs
 Pharmacy Track: DEA Regulations Update: Corresponding Responsibility and Proper Disposal
 PDMP Track: PDMPs as User-Friendly Clinical Decision Support Tools
 Treatment Track: Optimizing Utilization and Outcomes of Urine Drug Testing
 Third-Party Payer Track: PDMPs and Third-Party Payers: Workers' Compensation
 Trending Topics Track: The Naked Truth About “Medical” Marijuana: Translating the Science into
Messages that Matter
Tuesday, April 7, 2015 — Concurrent Block 4 (3:30 pm – 4:45 pm)








1.25 hours
Clinical Track: Alternatives to Opioids in Pain Management
Education & Advocacy Track: Collaboration, Coordination and Data: Three Keys for State Progress
Law Enforcement Track: Law Enforcement Responses to Fraud Rings, Burglaries and Robberies
Pharmacy Track: Expanding Role of Pharmacists in a Transformed Health Care System
PDMP Track: PDMPs as Public Health Surveillance Tools: Early Lessons from CDC’s Prevention Boost
Treatment Track: Preventing Opioid Overdose Deaths: Practical Skills for Clinicians
Third-Party Payer Track: Rx Drugs and Urine Testing: Knowing What’s Too Much, Too Little and Just Right
Trending Topics Track: Marijuana: Emerging Medical and Legal Issues
TOTAL DAY 2
_________
Page 2 of 3
Wednesday, April 8, 2015 — Concurrent Block 1 (11:15 am – 12:30 pm)




1.25 hours
Law Enforcement Track: Lessons from the Supply Side
Pharmacy Track: Identifying and Remedying Internal Diversion Issues
Third-Party Payer Track: Financial Toll of Rx Addiction
Trending Topics Track: Heroin: The Perfect Storm
Wednesday, April 8, 2015 — Concurrent Block 2 (12:30 pm – 1:45 pm)
1.25 hours
 Clinical Track: Diagnosis of Addiction and Impact of Pain
 Education & Advocacy: A Consensus Roadmap to Curb Deaths from Rx Drug Misuse and Abuse in the
U.S.
 PDMP Track: Ensuring Appropriate Prescribing: Using PDMPs to Identify & Address Problematic
Prescribing
 Treatment Track: The Evidence Base for Opioid Addiction Treatment and the ASAM Criteria
Wednesday, April 8, 2015 — Concurrent Block 3 (3:00 pm – 4:15 pm)
1.25 hours
 Clinical Track: State Initiatives Impacting Physicians and Patients
 Education & Advocacy: Parent Advocates Moving Legislation: Warm Hand-Off & Involuntary Treatment
Laws
 Law Enforcement: Enhancing the Role of Law Enforcement: Intervening in Rx Abuse and Protecting
Children
 Pharmacy Track: Lessons Learned from Rx Disposal Programs
 PDMP Track: Combining PDMP and Other Data to Combat Rx Drug Abuse
 Treatment Track: Inpatient and Outpatient Treatments for Pain and Addiction
 Third-Party Payer Track: Workers’ Compensation: Examining Policy Issues and What Works
 Trending Topics Track: Emerging Epidemic: Hepatitis C Infection among Young Persons Who Inject Drugs
Wednesday, April 8, 2015 — Concurrent Block 3 (4:30 pm – 5:45 pm)








1.25 hours
Clinical Track: Maternal-Fetal Issues for Physicians
Education & Advocacy Track: Using Social Media and Marketing for Rx Drug Abuse Education
Law Enforcement Track: Trends in Drugs of Choice
Pharmacy Track: Expanding Use of Naloxone
PDMP Track: Prescriber Viewpoint: How Mandating Compliance is Working
Treatment Track: Treatment as Part of the Community
Third Party Payer Track: Proactive Identification and Intervention Approaches
Trending Topics Track: Trends in Youth and Rx Drug Abuse
TOTAL DAY 3
_________
GRAND TOTAL FOR RX SUMMIT _________
Please comple, sign and return this form to clackey@twc.com or 606.677.6166 (fax).
Please complete your electronic evaluation by 11:59 p.m. ET on May 31, 2015.
For instructions, see CME/CE ELECTRONIC EVALUATION INSTRUCTIONS: STEP 2 OF 2.
Thank you!
Page 3 of 3