SLHS Continuing Medical Education Checklist
This mandatory form will assist you in planning, implementing and evaluating your activity. Failure to complete the form may result in no Continuing Medical Education credits being awarded for the activity.
Title of Continuing Medical Education Activity:
Advanced Practice Providers (APP) Grand Rounds
Cardiovascular Consultants Evening Educational Sessions Grand Rounds
Cardio Adult Congenital Heart Disease (ACHD) Case Conference
Cardio CICU Case Conference
Cardio Grand Rounds
Cardio MMI M&M
Echocardiography Physician Monthly Meeting Journal Club
Epilepsy Case Conference
GU Tumor Case Conference
Maternal-Fetal Case Conference
Medicine Grand Rounds
Medicine Journal Club
Medical Record Documentation Grand Rounds
Multidisciplinary Cancer Case Conference - Brain
Multidisciplinary Cancer Case Conference - Breast
Multidisciplinary Cancer Case Conference - Colorectal
Multidisciplinary Cancer Case Conference - GI
Multidisciplinary Cancer Case Conference - GYN
Multidisciplinary Cancer Case Conference – Head and Neck
Multidisciplinary Cancer Case Conference - Thoracic
Multidisciplinary Wound Care / Limb Preservation Case Conference_St. Luke's South / St. Luke's East
Multi-Specialty Vascular Case Conference
Neonatal ICU Peer Review M&M
Neonatal Journal Club
Neuroscience APP Case Conference
Neuroscience Grand Rounds
Neurovascular Case Conference
Orthopaedic Case Conference
Precision Oncology Tumor Board Case Conference
STEMI Peer Review M&M
Structural Heart Case Conference
Surgery Grand Rounds
Trauma Grand Rounds
Trauma Peer Review M&M
Vascular Surgeon Case Conference
Date of Activity:
If this activity has multiple formats, please define the type of activity for the specified date:
Activity Coordinator Name:
Activity Coordinator E-Mail:
PRIOR TO ACTIVITY
1. Did you provide advance notice for this Activity (E-mail notification, flyer, electronic announcement...)
Yes (If yes, a copy must be approved by INMED prior to publication and distribution)
Please provide a copy of the notice provided for the activity. (A pdf of the email notification, flyer, electronic announcement, etc)
2. Did INMED provide to you an updated Credit Claim Form and/or PowerPoint slide that reflects the Accreditation Statement, Learning Objectives, Speaker information and date of the Activity?
No (If no, please contact INMED for updated Credit Claim Form)
3. Was a Disclosure Form submitted to INMED for the Speaker/Presenter within the required time frame?
4. Was this Activity free from influence of Ineligible Companies? (No industry representative had any input into the preparation of this activity.)
If No, please explain:
5. Was this Activity free from Third-Party financial or in-kind support (including food)?
If No, please explain:
DURING THE ACTIVITY
6. Was Planning Committee and Speaker disclosure information made available to attendees and listed on the Credit Claim Form and/or PowerPoint slide prior to the Activity?
7. Activity Format:
This Activity was Live (In-Person) Only
This Activity was both Live and Online/Virtual
This Activity was Online/Virtual Only
Upload completed activity Credit Claim Form, if applicable.
You can also upload additional documents here. Maximum of 3 files.
8. EDUCATIONAL REPORTING (Only for Case Conferences, M&M and Tumor Boards) Please upload Meeting Minutes/Agenda OR complete Questions 8a-8c.
Upload Meeting Minutes/Agenda/Slides:
8-a Medical issue(s) captured as identified by specific case(s) selected:
8-b Outline of discussion (simple notes from meeting that does not include identifying patient information):
8-c Educational take-away point(s) from discussion of patient case(s), including adverse outcomes &/or death:
Contact CME@inmedce.com or call 816-444-6400 x3.
Should be Empty: