Sample CME Attendance Worksheet
University of Oklahoma College of Medicine
Instructions for Obtaining AMA PRA Category 1 Credits™
Activity Title
CME Course Number
For Physicians to officially receive AMA PRA Category 1 CreditsTM and for Non-Physicians to
document their attendance, participants are required to complete both the attendance worksheet
and the activity evaluation online.
The following form is only an attendance worksheet; your certificates will be mailed to you 4-6
weeks after we have received your completed worksheet and online evaluation. Evaluations
are open for only three weeks after the activity.
Attendance Instructions – Record your attendance on the worksheet below by filling out and
totaling the ‘Time Earned’ column to accurately reflect your attendance. Physicians should only
claim the credit commensurate with the extent of their participation in the activity.
Return the completed worksheet to the registration table at the close of the conference, or mail it
to Irwin H. Brown Office of Continuing Professional Development (CPD) University of
Oklahoma College of Medicine (OU/COM), P.O. Box 26901, ROB 202, Oklahoma City, OK
73126-0901, where it will be processed.
Evaluation Instructions – After attending this activity, you will be emailed a link to the
evaluation. ALL participants are required to evaluate the activity to receive credit. OU/CPD
will track attendance and evaluations. If you do not receive an email within one week, please
contact Susie Dealy in the OUHSC/CPD office by sending an email to Susie-dealy@ouhsc.edu
or calling 405-271-2350, ext. 1. Please Note: Some e-mail servers do not recognize the e-mail
from OUHSC and will place it in a “junk” or “spam” file. The evaluation link will be included
in the e-mail from Susie Dealy, so please add Susie-dealy@ouhsc.edu as a contact in your
contact/safe senders list or check your e-mail “junk or spam” folder for her message.
Evaluations are open for only three weeks after the activity. Evaluation forms are
programmed to open at the end of the activity and close three weeks later. If you have
difficulties with our online evaluation, please call us at 405-271-2350 or
888-682-6348.
Our website address is: http://cme.ouhsc.edu
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University of Oklahoma College of Medicine
Office of Continuing Professional Development
Sample Attendance Worksheet
Activity Title
Activity Date
Activity Location
CPD/CME Course Number
(PLEASE PRINT CLEARLY)
___________________________ __________________________________ ___________________________________________
First Name
Middle Name
Last Name
Please indicate status (needed for CME credit purposes):  M.D.  D.O.  Resident  Other ___________________
Address: __________________________________________________________________________________________________
______________________
(City)
_____ __________
(State)
(Zip)
( ____ ) _____ _________
___________ _______ ______________
Social Security Number (Needed to track credits)
(Daytime Phone Number)
_____________________________________________________
E-mail Address
Consent: Please indicate whether you consent to the receipt of future electronic messages from OU/COM CPD regarding future activities or
surveys? __Yes or __No. We will not share your e-mail or contact information with anyone outside of OU/COM CPD.
___________________________________ ____________ Specialty: _____________________________________
Participant Signature
Degree
Time
Avail.
Date of the Activity
The title of each presentation and the presenter’s name is listed on this table.
The title of each presentation and the presenter’s name is listed on this table.
The title of each presentation and the presenter’s name is listed on this table.
The title of each presentation and the presenter’s name is listed on this table.
The title of each presentation and the presenter’s name is listed on this table.
The title of each presentation and the presenter’s name is listed on this table.
The title of each presentation and the presenter’s name is listed on this table.
The title of each presentation and the presenter’s name is listed on this table.
The title of each presentation and the presenter’s name is listed on this table.
Total Minutes Actually Spent in CME Activity
This activity was designated for AMA PRA Category 1 Credits TM
Time
Earned
30
30
30
30
30
45
30
60
75
360
6.00
NOTE: Individual times are in minutes. To get total credits, total the minutes and divide by 60. (Note: Credits should be
expressed in terms of whole, half or quarter units of time, with the time rounded to the nearest whole, half or quarter credit.)
No Credit (*0). If applicable, the topic(s) did not meet the definition of CME and/or the credits for this session were eliminated due to unresolved disclosure issues.
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