Contents of Facilitator Packet
To Be Distributed to Each Participant
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Statement of attendance
Comments form
Upcoming events notice
Disclosure and accreditation
To Be Faxed or Emailed Immediately After the Presentation
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Sign-in sheets
Statements of attendance
Participant comments forms
Facilitator evaluation
Please completed and submit all forms the DAY OF THE PRESENTATION.
Fax it to 501-686-8741 or scan and email to ALMueller@uams.edu.
Please note that if you have problems connecting or any other technical issues, please call
the technical support hotline at 501-686-8666. If you call the CME office with technical support
questions, it will just prolong your wait time. We do not have the capabilities at our site to help you
with IT problems.
Alecia Hamilton
Director
DFPM-CME
AHamilton@uams.edu
DIVISION OF CONTINUING
MEDICAL EDUCATION
4301 West Markham, Slot #530-3
Little Rock, AR 72205
501-686-6617
www.cme.uams.edu
Friday, March 13, 2015
“Nutrition and Cancer”
(Part of the 18th Annual Charles William Rasco, III
Symposium on Colorectal Cancer and GI Malignancies)
Robert E. Wolfe, PhD
Dear Facilitator:
We are happy you have decided to join us for this session. We have put together this packet of information and
necessary materials to assist you in organizing your programs. These documents are required for continuing
medical education institutional compliance. Please note the materials which need to be returned immediately
after the program.
Certificates will be emailed or mailed in April, so please be sure all participants include a valid email address if
possible.
Please note: The Arkansas State Board of Pharmacy accepts AMA PRA Category 1
Credits™. Certificates will serve as proof of program credit and hour(s).
To promote interaction on the day of the program, each site will be asked for questions at the end of the
presentation. Make sure you mute your microphone until the Q&A portion since any sounds from your site will
be heard during the presentation.
The Arkansas State Board of Pharmacy requires that all participating pharmacists note the time that they sign
in and out to show attendance during the entire session in order to get credit. Please record the time of arrival
and departure on the sign-in sheet; otherwise, we will be unable to offer accreditation.
If you have any questions, please give CME associate Lynn Mueller a call at 501-526-5439.
Best regards,
Alecia Hamilton, MA
Director of Continuing Medical Education
University of Arkansas for Medical Sciences
College of Medicine
Department of Family and Preventive Medicine
Facilitator Evaluation
Friday, March 13, 2015
“Nutrition and Cancer”
(Part of the 18th Annual Charles William Rasco, III
Symposium on Colorectal Cancer and GI Malignancies)
Site Location:
Facilitator contact information:
Name:
Email:
Phone:
Please submit all of your completed paper work by fax or email THE DAY OF THE
501-686-8741. You may also scan the records and email to ALMueller@uams.edu
PROGRAM. Our fax number is
Your comments and suggestions are very helpful in providing quality presentations.
We appreciate the time and effort that you put into today’s session.
5 = Excellent
4 = Good
3 = Satisfactory
2 = Poor
1 = Undecided
The interactive video presentation: (circle one or write answer)
1. Offered sufficient notice of program
5
4
3
2
1
2. Was well organized
5
4
3
2
1
3. Quality of Technology
5
4
3
2
1
5
4
3
2
1
(Please give a written response to items A-E)
A. Did you have any technical issues?
B. How many people attended?
C. How was the presentation?
D. Technical contact person’s name:
E. Were you able to contact technical support?
4. Overall
How can we provide a better working relationship with facilitators?
Facilitator Evaluation
Sign-In Sheet
Friday, March 13, 2015
ITV Broadcast
“Nutrition and Cancer” by Robert E. Wolfe, PhD
(Part of the 18th Annual Charles William Rasco, III Symposium on Colorectal Cancer and GI Malignancies)
Site: ____________________________________
(SIGN-IN SHEETS MUST BE TURNED IN TO RECEIVE CREDIT)
Printed Name
(Please Print Legibly)
Signature
Degree (MD, APN,
RN, etc.)
Pharmacist
Please Write Time
IN
OUT
STATEMENT OF ATTENDANCE
In order to receive CME credit, this page MUST be filled out COMPLETELY.
Return to the Registration Desk or to UAMS CME Office:
Continuing Medical Education Division, 4301 West Markham, Slot #530-3, Little Rock, AR, 72205
Friday, March 13, 2015
“Nutrition and Cancer”
(Part of the 18th Annual Charles William Rasco III Symposium
on Colorectal Cancer and GI Malignancies)
ITV Broadcast from Little Rock, AR
TIME FRAME
SESSION NAME
CREDITS
AVAILABLE
Noon – 1 p.m.
“Nutrition and Cancer”
Robert E. Wolfe, PhD
1.00
TOTAL CREDITS AVAILABLE
# CREDITS
ATTENDED
1.00
TOTAL CREDITS CLAIMED
PLEASE PRINT LEGIBLY. If this information is not legible, we will not be able to enter the credits claimed.
All information below is required in order to award credits.
All information obtained is confidential, for internal use only, and will not be shared.
I attest that I attended the hours indicated above.
Last 4 of SSN: xxx-xx-
Pharmacy License# (If applicable)________________
Firm/Affiliation:
Medical Specialty
PRINTED Name
Degree/Title
(AS YOU WANT PRINTED ON YOUR CERTIFICATE)
Email
Phone
Mailing Address
City
County
State
Zip
UAMS Alumnus
Signature
Certificate Announcement:
Please note that certificates will be mailed or emailed April 2015.
Comments
Friday, March 13, 2015
“Nutrition and Cancer”
(Part of the 18th Annual Charles William Rasco III Symposium on
Colorectal Cancer and GI Malignancies)
Robert E. Wolfe, PhD
1. Describe anything exceptional about the presentation.
2. Describe anything that did not meet your expectations about the presentation.
3. Please describe any clinical situations that you find difficult to manage or resolve that you
would like to see addressed in future educational activities:
Additional comments:
Upcoming Events
ITV: Oncology Update for Primary Care
April 7, 14, 21 & 28, 2015, Noon – 1 p.m.
Topics to cover cancer survivorship, nutrition and cancer, screening
and treatment of prostate cancer and improving communication
about cancer with patients.
Leaving a Trail of Smoke: Tobacco’s Impact on Health FREE!
Thursday, May 14, 2015, 9:30 a.m. – 4 p.m.
BreastCare Sessions
Friday, May 15, 2015, Noon – 2 p.m.
“Chemoprevention of Breast Cancer”
Noon - 1 p.m.
“You Are the Key to HPV Cancer Prevention”
1 p.m. – 2 p.m.
37th Annual Family Medicine Intensive Review Course
8 a.m. – 4 p.m.
May 14 – 17, 2015
Jackson T. Stephens Spine and Neurosciences Institute, 12th
Floor, UAMS
Save the Date
WISEWOMAN ITVs
June 2 & 9, 2015, Noon – 1 p.m.
For more information about our programs, contact us at
(501) 526-5439 or www.cme.uams.edu
Contact our office to be added to our mailing list to receive notice of all our programs.
UAMS Disclosure Policy
It is the policy of the University of Arkansas for Medical Sciences (UAMS) College of Medicine to ensure balance,
independence, objectivity and scientific rigor in all sponsored or jointly sponsored educational activities. All
individuals who are in a position to control the content of the educational activity (course/activity directors, planning
committee members, staff, teachers or authors of CME) must disclose all relevant financial relationships they have
with any commercial interest(s) as well as the nature of the relationship. Financial relationships of the individual’s
spouse or partner must also be disclosed, if the nature of the relationship could influence the objectivity of the
individual in a position to control the content of the CME. The ACCME describes relevant financial relationships as
those in any amount occurring within the past 12 months that create a conflict of interest. Individuals who refuse to
disclose will be disqualified from participation in the development, management, presentation or evaluation of the
CME activity.
Disclosures
The following planning committee members and/or speakers of this CME activity have no relevant financial
relationships with commercial entities to disclose:
Mohit Girotra, MD
Liudmila Schafer, MD
Julie Goodwin, PhD, RN
Frederick Bentley, MD
Dan Brown, MD
Sidney Keisner, PharmD, BCPS, BCOP
Jonathan Laryea, MD
Matthew Hardee, MD
James Meek, MD
Lori Phares, BSN, RNP, CWOCN
Mazin Safar, MD
Daniel Borja-Cacho, MD
Dorothy Graves, PhD
Alecia Hamilton
Lanette Nimmer
Libby Stell, RNP
Jenny Thiltgen
Cynthia Howington, APN
The following planner and/or speakers of this CME activity have financial relationships with commercial
entities:
Issam Makhoul, MD
1. Eli Lilly: Grant/Research Support
2. Genentech/Roche: Grant/Research Support
3. New Link: Grant/Research Support
4. Shula Foundation: Grant/Research Support
Robert Wolfe, PhD
1. Baxter: Grant/Research Support
2. Abbott: Grant/Research Support
3. Dannone: Grant/Research Support and Meeting Travel Expenses
Accreditation
UAMS Department of Family and Preventive Medicine is an approved provider of continuing nursing education
by Arkansas Nurses Association, an accredited approver by the American Nurses Credentialing Center’s
Commission on Accreditation.
Up to 1.00 contact hours will be awarded to nurses who turn in an evaluation form for each contact hour
completed.
The University of Arkansas for Medical Sciences (UAMS) College of Medicine is accredited by the Accreditation
Council for Continuing Medical Education to provide continuing medical education for physicians.
The UAMS College of Medicine designates this live activity for a maximum of 1 AMA PRA Category 1
Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the
activity.