Continuing Medical Education Documentation Record

For Compliance With Section 166.2 of the Texas Medical Practice Act

Do not submit this form to the Texas Medical Board unless specifically requested.

This form represents only one format which may be useful for physicians to record their CME hours. This is NOT an official form of the Texas Medical Board  and is NOT required for compliance with the CME requirements. If used, this form should be retained as a personal record only.

Formal CME Activities Completed

Name: __________________________________ 

Lic. Number __________________________

From:___________________, 200____ To: ______________________, 200 ____
(date of current license)                              (date of next registration)

At least 12 hours every 12 months, including 1 hour of ethics and/or professional responsibility education, must be completed through participation in formal CME activities, but all 24 hours may be completed in this category.

Formal CME activities are defined as conferences, seminars, symposia, case conferences, grand rounds, educational presentations, self-study courses or materials, etc. which are:

  • Designated for Category 1 credit of the Physician's Recognition Award of the American Medical Association
  • Approved for prescribed credit by the American Academy of Family Physicians
  • Designated for Category 1A and 2B credit of the American Osteopathic Association

 

 


Activity Title

Date
# of Credit Hours Type of Credit (AMA, AAFP, AOA)
     
     
     
     
     
     
     
     
     
     
     

Return to Rules for Reporting CME
Return to License and Regulations


Comment on this (Must be logged in to comment)

Add Comment

Text Only 2000 character limit

Looking for more?