Mutual Gravity - Survey Report

LECOM Clinical Rotation & Preceptor Continuing Medical Education Form

Dear Physician,

Thank you for participating in the education of a LECOM medical student. By working with the student, you earn one (1) category 1-B continuing medical education credit for each hour of instruction. For example, if you work 160 hours with a student, we will submit 160 CME credits. We will submit all of your teaching hours to the AOA, however,
the AOA will only use 20 hours per year to meet a physician's AOA CME requirement.

To receive these credits, please complete the information requested below. LECOM CME staff submits credits to the AOA at the end of each quarter. If you are not a member of the AOA, or require a printed certificate, LECOM CME will send you a copy of your hours. Please contact the CME office (814) 860-5125 or by Email at cme@lecom.edu.

Your support of LECOM’s educational goals and our students is greatly appreciated.

Please provide your contact information.

AOA Number
Physician First Name
Physician Last Name
Degree: DO or MD
Medical Specialty

Office
Address
City
State
Postal Code
Phone
FAX

Please provide your Email address:

Please include the student's name, the number hours of clinical teaching you are requesting for CME and the start and end dates of the clinical rotation.

Student First Name
Student Last Name
Class Year
CME Hours requested
Start Date
End Date

By submitting this request for Clinical Rotation CME credit, I attest to having taught the number of hours listed.

If you need your hours reported immediately, or if you require a CME certificate, please contact the CME office (814) 860-5125 or by Email at cme@lecom.edu.

You may also download a paper version of this form from the LECOM CME website and fax that form to (814) 866-8408.