Learning Associated with Teaching Medical Students and Residents
Credit Documentation Form
Please review the Learning Associated with Teaching Instruction Handbook before completing this form.
This form should be completed after instruction has taken place. To accurately document the learning the physician gained in
preparing for the teaching activity, one form should be completed per teaching activity, where you as an instructor engaged in
new learning. Refer to the examples listed in the handbook.
Instructions: Submit this form to UI-COM Office of Continuing Medical Education (CME) to claim CME credit for the preparation
followed by teaching of medical students, residents or fellows in ACGME-approved programs. To qualify, you must engage in new
learning which you then put to use in your role as a medical educator. This form must be submitted no later than four weeks after
your date of teaching.
Allotment of Credit Hours: Physicians may receive 2 AMA PRA Category 1 credits™ for each hour they engage in teaching of medical
students, residents or fellows. The learners must be in at least one of the groups listed below. Teaching in non-LCME or non-ACGMEapproved programs does not qualify. You may receive credit only once for the specific teaching activity.
Example Scenario: A faculty member is asked to give an interactive skills-based workshop on “Sinusitis” designed to address medical
students’ inability to evaluate patients appropriately for this condition. The faculty member identifies, through self-assessment, that
she does not know the anatomy of the sinuses, does not know the pathophysiology of these processes, and does not have a personal
strategy in place for taking a history regarding sinusitis or for examining the patient. Therefore, she conducts her own personal
learning project to address these needs—and can then describe what new strategies she develops as a result. Also during this
process, she learns several new skills associated with including x-ray images and 3D-imaging videos in her educational presentations
using software tools.
For more sample scenarios, see the Learning Associated with Teaching Instruction Handbook.
NAME:
DEPARTMENT:
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E-MAIL:
DATE TAUGHT:
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Who were your learners? (Check all that apply)
☐ Medical Students
☐ Residents
☐ Fellows
☐ Mentorship
☐ Scholarship
☐ Service Learning
What was your role as a teacher? (Check all that apply)
☐ Assessing performance
☐ Case development
☐ Instructing how to teach
☐ Instruction: clinical
☐ Instruction: research
☐ Instruction: skills building
☐ Formal presentation
☐ Mentoring
☐ Supervision: simulation
☐ Other scholarly activities (Please specify: ____________________________________________________)
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What did you set out to accomplish? Describe how this learning project informed or improved your professional
practice of teaching. Describe this in terms of new knowledge sought or gained, or a new strategy or practice you
developed.
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Describe what you did as an active learner to complete this project. What learning resources did you use?
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In completing this learning project, please describe:
1. What you learned
2. When and where you can apply this learning
3. The outcome(s) you had
4. The impact this learning will have for you, your students, or the system in which you work
5. The barriers you expect to encounter (if any) and the countermeasures you can use
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What competencies might this assist with? (Check all that apply)
☐ Clinical practice / patient care / procedural or technical skills
☐ Communication skills
☐ Medical knowledge
☐ Practice-based learning / improvement
☐ Professionalism
☐ System-based practice
☐ Other (Please specify: ____________________________________________________________)
How much time did you spend teaching? (Please use quarter hour increments)
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I attest that the above information is correct: ________________________________________ Date: ____________
The University of Illinois College of Medicine is accredited by the Accreditation Council for Continuing Medical Education
to provide continuing medical education for physicians.
The University of Illinois designates this live activity for a maximum of 2 AMA PRA Category 1 credits™ per 1 hour of
interaction with medical students and/or residents/fellows. Physicians should claim only the credit commensurate with
the extent of their participation in this activity.
CME Office Use Only
Approved for __________ CME credit hours
Approval: _________________________________________
Date: ________________________________