Faculty Credit Claim Form

In order to receive AMA PRA Category 1 Credits™, you must complete each field below:

Meeting Name or Educational Activity:

Session Title:

Presentation Title:

Date of Presentation:
(MM/DD/YYYY)

Time of Presentation:

Please complete a separate form for each session
in which you served as faculty

First Name: Last name:

Designation: MD DO

Address:

City: State: Zip:

Country: (if not USA)

SIR Membership Number:
(If not included data will not transfer to CME Gateway)

Email address:

Phone: Home Work

Certificates will be generated upon review of this submission and you will be notified by email when your certificate can be downloaded. Please assure that your email address is accurate

Documentation of the Educational Process

Please use the following rating scale to evaluate this activity. Strongly Agree, Agree, Disagree, Strongly Disagree. Choose only one rating for each statement.

1. This teaching process prompted me to critically review existing literature.

2. This teaching process prompted me to synthesize the existing literature with my experience and proposed presentation.

3. This teaching process prompted me to identify the strengths of, and areas needing improvement in interventional radiology.

4. This teaching process prompted me to identify the strengths of, and areas needing improvement in my own practice.

5. Participating in this teaching process and interaction with the learners improved my understanding of the diagnostic and/or therapeutic technique(s) covered in my presentation.

I claim AMA PRA Category 1 credit(s)™ for participating as faculty in this activity (2 credits for each hour of interaction with learners).

By checking this box, I affirm that this was an original presentation, prepared for this Society of Interventional Radiology activity. I understand that I cannot claim credit for this presentation in another venue, nor can I claim credit for presentations I may have made prior to this activity.