American Diabetes Association
65th Scientific Sessions
June 10 - 14, 2005
REQUEST FOR CERTIFICATE/STATEMENT OF CREDIT
To receive a Certificate/Statement of Credit, you must complete and return this request form. Email this form
as an attachment to professionaleducation@diabetes.org or fax it to 703-549-1715 or 703-253-4876. If you
have questions please contact Audrey Shively at professionaleducation@diabetes.org.
Type of CE requesting:
_____Physician_____International Physician_____Nurse ____Dietitian _____Pharmacist____Podiatrist
_____Psychologist_____CDE_____Other, please list__________________
Number of credit hours requesting: _______________________
Name: _______________________________________Degree(s): ___________________________
Employer: ____________________________________ License No (not required):______________________
Email:____________________________ Fax:_______________________ Tele:________________________
Mailing Address:____________________________________________________________________
City, State, Zip Code: ________________________________________________________________
_______________________
Signature
_______________
Date
Physicians: The American Diabetes Association is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical
education for physicians. The American Diabetes Association designates this continuing medical education activity for a maximum of 29.25 hours in Category 1 Credit
toward the Physician’s Recognition Award of the American Medical Association. Each physician should claim only those hours of credit he/she spent in the
educational activity. The American Medical Association has determined that physicians not licensed in the US who participate in this CME activity are eligible for
AMA PRA category 1 credit.
Nurses: The American Diabetes Association is approved as a provider of continuing education in nursing by the Virginia Nurses Association, an accredited approver by
the American Nurses Credentialing Center’s Commission on Accreditation. The American Diabetes Association is located at 1701 N. Beauregard Street, Alexandria,
VA 22311. VNA Provider No. 04-03-02. This education activity is approved by the Virginia Nurses Association (VNA) which is accredited by the American Nurses
Credentialing Center’s Commission on Accreditation as an approver of continuing education in nursing for a maximum of 35.0 VNA contact hours. The VNA is
located at 7113 Three Chopt Road, Suite 204, Richmond, VA 23226. The American Diabetes Association is a provider approved by the California Board of Registered
Nursing, Provider No. CEP-12196, for a maximum of 29.25 contact hours.
Dietitians: This activity has been approved by the Commission on Dietetic Registration (CDR) for a maximum of 29.25 hours of continuing professional education
credit.
Certified Diabetes Educators: To satisfy the requirement for renewal of certification by continuing education for the National Certification Board for Diabetes
Educators (NCBDE), continuing education activities must be diabetes related and approved by a provider on the NCBDE List of Approved Providers (www.ncbde.org).
NCBDE does not approve continuing education. The American Diabetes Association is on the NCBDE List of Approved Providers.
Pharmacists: The American Diabetes Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing
pharmacy education. This activity provides up to 29.25contact hours of continuing pharmacy education credit. The ACPE program number is 239-00005-004-C01. Each pharmacist should claim only those hours of credit that he/she spent in the education activity.
Podiatrists: The Association has been granted affiliate sponsorship from the American Podiatric Medical Association to offer 29.25 continuing education credit hours to
podiatrists for this activity.
Psychologists: The American Diabetes Association is approved by the American Psychological Association to offer continuing education for psychologists. ADA
maintains responsibility for the program. This activity has been approved for a maximum of 28.0 hours of continuing education credit. Each psychologist must attend
in their entirety those sessions designated as approved for psychology credit and claim only those hours spent in the educational activity.