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DOCUMENTATION FOR CONTINUING EDUCATION CREDIT

Dartmouth Pediatric Conference

March 3-6, 2011
Omni Mount Washington Resort, Bretton Woods, NH

To receive continuing education credit, please complete this form.

The Dartmouth-Hitchcock Medical Center designates this live activity for a maximum of 15 AMA PRA Category 1
Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The Dartmouth-Hitchcock Medical Center is accredited by the Accreditation Council for Continuing Medical Education
(ACCME) to provide continuing medical education for physicians.

Dartmouth-Hitchcock Medical Center’s Nursing Continuing Education Council is accredited as a provider of continuing
nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
This educational activity carries 15 contact hours.

* 1. What is your degree or profession?

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n MD/DO

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n PA

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n NP

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n RN

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n Other (please specify)

* 2. Please check below the sessions you attended on THURSDAY, MARCH 3rd
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g Prevention of Meningococcal Disease in Infants, Children and Adolescents & Other Emerging Immunization Issues (.75)

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g Cystic Fibrosis: Improving Clinical Outcomes with Currently Available Tools While Waiting for the Ultimate Cure (.75)

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g Sexual Behaviors in Children: What’s Normal? What’s Not? (1.00)

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g Did not attend this day

* 3. Please check below the sessions you attended on FRIDAY, MARCH 4th
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g Polycystic Ovarian Syndrome (PCOS): Who Has It? Who Doesn’t? Who and How do we treat? (.75)

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g Adolescent Sexuality (.75)

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g Prepubertal Bleeding without Thelarche (.75)

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g Female Athlete Triad 2011 (.75)

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g Sex, Menses, and Teens: Case-Based Panel and Attendee Discussion (1.00)

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g Did not attend this day
* 4. Please check below the sessions you attended on SATURDAY, MARCH 5th
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g Common Issues in Pediatric Office Orthopaedics (.75)

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g Scoliosis in Children: Assessment, Follow-up and Treatment Principles (.75)

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g The Limping Child (.75)

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g Assessing Lower Extremity Alignment (.75)

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g Developmental Dysplasia of the Hip (.75)

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g a. Newborn Hip Exam (break-out session) (.75)

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g b. Scoliosis and Leg Length Discrepancy (break-out session) (.75)

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g c. Lower Extremity Alignment (break-out session) (.75)

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g Did not attend this day

* 5. Please check below the sessions you attended on SUNDAY, MARCH 6th
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g Health Care Reform: A Current View of the Patient Protection & Affordable Care Act and Its Implementation Almost a Year Out (1.00)

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g Pediatric Obesity: Tackling an Epidemic (1.00)

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g The Economics of Nutrition through a History of E. Coli O157:H7 (.75)

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g Cholesterol: What Pediatricians Should Know for their Patients and Themselves (1.00)

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g Conference Wrap-up, Final Comments & Suggestions (.25)

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g Did not attend this day

* 6. Please select one:

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g Physician (I want CME)

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g Non-physician (I want CME)

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g Non-physician (I want Contact Hours)

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g Nurse (I want Contact Hours)
* 7. By entering my name below, I certify that I have attended the indicated sessions and
should receive credit for the boxes I checked.
Last Name

First Name

Middle Initial

Degree

Email address

Street address

City

State

Zip code

Telephone