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CME Self Test

Credits provided by the American College of Sports Medicine

To receive credit verification, print, fill out and sign the form confirming you have read the materials and obtained a minimum passing score.

Issue Month & Year: _____________________

Expiration Date: ____________

Credits: ____________

Preferred credit hour type (check only one):

___ AMA (CME Category 1)

___ ACSM (CEC)

___ NATA (CEU)

Evaluation of credit offering:

1. Was material: ___ New or ___ Review for you?

2. Do you feel the program was fair, balanced and free of commercial bias? ___ Yes ___ No

If no, please state reasons:________________________________________

3. Did material meet the learning objectives? ___ Yes ___ No

4. Will you be able to use the information learned from this credit offering in your profession?: ___ Yes ___ No (i.e., treat/manage patients, communicate with patients, manage my medical practice, etc.)

If yes, how:___________________________________________________

Please attach business card, print legibly, or type on each form:

Name: _______________________________________________ Degree: _____________

Address: ______________________________________________________

City: _____________________ State: _____ Zip: _______________

Business Phone: (_____)____________________

Fax: (_____)____________________

___ ACSM Member (ACSM ID# ______________________)

___ Nonmember

I attest that I have read the articles and answered the test questions using the knowledge gained through the articles provided in this issue and received a passing grade (minimum score 60%).

I am claiming _____ number of credit hours (Each physician should claim only those hours of credit that he/she actually spent in the educational activity).

Signature: ____________________________________ Date: __________

___ Change my address as shown above, effective date: __________

To receive credit, mail these pages or photocopies of them, with check or money order in the amount of $15 (ACSM members) or $20 (nonmembers) for each CME Self Test to:

Education Department
American College of Sports Medicine
Box 1440
Indianapolis, IN 46206-1440 USA.

Please allow 4-5 weeks for processing.