Citi basic Course in the Protection of Human Research Subjects Credit Request Form

CITI Basic Course in the Protection of Human Research Subjects
Credit Request Form

To receive credit, mail this form to the University of Miami, Division of Continuing Medical Education at the address listed below (or fax with credit card payment).
Credit is available for the period of July 1, 2006 thru June 30, 2009.
ACCREDITATION: The University of Miami Miller School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.
CME CREDIT HOURS: The University of Miami Miller School of Medicine designates this continuing medical education activity for a maximum of 6 category 1 credits toward the AMA physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.
PSYCHOLOGY CREDITS: The University of Miami Leonard M. Miller School of Medicine is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. The University of Miami Leonard M. Miller School of Medicine maintains responsibility for this program and its content. 6 CE credits will be awarded to psychologists for participation in this course

Name:		Degree:	SSN: (Last 4 only):
Address:	City, State, Zip:
Telephone:	FAX:		Email:
Specialty	For verification purposes, please provide USERNAME:

INDICATE TYPE OF Certificate REQUESTED (by placing a check mark in the appropriate box)

Physician Category 1 AMA/PRA CME	Psychologist CE	CERTIFICATE OF COMPLETION Nurses/Allied Health Professionals
CERTIFY COURSE COMPLETION I certify that I have completed the CITI Basic Course in the Protection of Human Subjects as designed. Indicate the total amount of time you spent completing this educational activity:       A maximum of 6 credits will be awarded for completion of all 12 modules. Signature: Date:

TUITION: $80

Check enclosed in the amount of $       (U.S. Dollars) made payable to: UM, Division of CME.

Please charge my registration fee in the amount of $       to my:  Visa®  MasterCard®  Discover®

Card Number      

Expiration Date      

Name on Card      

Authorized Signature _____________________________________

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Please answer the following questions using the rating scale: 4 = Strongly Agree ..........1 = Strongly Disagree

(Do not evaluate any objective listed below that did not apply to the modules you completed)

The program met the following objectives: Upon completion of this online course participant should be able to:

Have a greater awareness and understanding of the federal regulations and policies, which protect human subjects in the research environment	4 3 2 1
Gain new insights of how to improve human subjects research study design through greater attention of potential risks and harms associated with human subject participation in research	4 3 2 1
Have a greater appreciation of the Belmont Report as the foundation of US policies toward human subjects research	4 3 2 1
Have a better understanding of how to improve human subjects research study design through greater attention to potential risks and harms associated with human subject participation in research	4 3 2 1
How risks and potential harms associated with participation in social and behavioral human subjects research are less predictable with respect to occurrence, effect and long term outcome	4 3 2 1

University of Miami School of Medicine

Division of Continuing Medical Education

PO Box 016960 (D23-3), Miami, FL 33101

Tel: [phone] Fax: [phone]

Webpage: http://cme.med.miami.edu