CME Reporting Form

2024 Annual Convention

July 23-27, 2024 Suncoast Hotel, Las Vegas, NV

Per the policy guidelines for Virtual and On-Site Monitoring for Continuing Medical Education (CME) Programs, implemented by the American Osteopathic Association (AOA) Board of Trustees, all CME providers are required to obtain a signed CME Reporting Form for each sponsored CME activity.

CME credits will not be submitted to the AOA without submission of this signed form to the Nevada Osteopathic Medical Association.

Forms submitted after September 6, 2024 may be assessed for an additional $35.00

First Name *

Last Name *

Email *

Phone *

“Nevada Osteopathic Medical Association is accredited by the American Osteopathic Association to provide osteopathic continuing medical education for physicians. The Nevada Osteopathic Medical Association designates this program for a maximum of 36 hours of AOA Category 1-A credits and will report CME and specialty credits with the extent of the physician’s participation in this activity.”

To fulfill your accreditation requirements, please indicate your attendance below.

Conference OMT Workshop *

Primary Track CME

Required Topics

Ethics *

Suicide Prevention *

Pain Management *

HIV Stigma, Discrimination, and Unrecognized Bias *

Cultural Competency and Diversity, Equity, and Inclusion *

Hours Attended Excluding Above SPECIFIC Requirement Hours

How did you attend the Symposium in 2024?

On-Site with OMT Workshop (36 hours max)

On-Site Primary Track (32 hours max)

Online Only (32 hours max)

Total CME Hours Attended *

Board Certified/Eligible In *

AOA Number

Printed Name *

Attesting Signature The Above is Accurate *

Clear

Nevada Osteopathic Medical Association

2245 Springdale Court Reno, NV 89523

855-888-NOMA Fax: 775-384-2865

[email protected]