Complete this form to submit your learning from teaching credit request. Be prepared to have your verification form from your GME Residency office. 

 

Accreditation

In support of improving patient care, The University of North Texas Health Science Center at Fort Worth is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing Education for the healthcare team. 

The University of North Texas Health Science Center at Fort Worth is accredited by the American Osteopathic Association to award continuing medical education to physicians. 

Designation

The University of North Texas Health Science Center at Fort Worth designates this activity for a maximum of 2.0 AMA PRA Category 1 Credit(s)™ per 1 hour of teaching interaction with medical students and/or residents/fellows. Physicians should only claim credit commensurate with the extent of their participation in the activity. 

 
1 Start 2 Complete
What is the name of the teaching activity you learned from?
What were the dates of your "Learning from Teaching" experience?
What is the title/topic you taught?
What was the format of the teaching activity? Check all that apply.
What was the length of your presentation or involvement to the nearest quarter hour?
Gap Identified: What was the nature of your Education Gap?
Describe Gap: (Describe the clinical knowledge/skills gap and/or gap in education technique and understanding.)
Describe Educational Need: (Describe/list new knowledge sought, new strategy or practice to be developed.)
Which of the following competencies were involved in your learning? (Please check all that apply.)
Knowledge Sources: Share any textbooks, abstracts, review of current literature; chart review and analysis; other reading; consultation; online searching for teaching, information-sharing, etc.
Resulting Change in Skills/Knowledge: (e.g., improved teaching skills, better understanding of pathophysiology, improved patient management or outcomes)
Reflection and Application: (What did you learn? What will be the outcome of this learning for you or your patients or the system in which you work? What barriers to implementation exist for you and how will you address these?)
Name of Course Director, Program Director, Clerkship Director, Chair, or Division Chief that may be contacted for verification.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf docx.
Attestation: