Faculty and Fellow Activity Log

Faculty and Fellow Activity Log

First Name*

Last Name*

Email*

Degree*

Activity Date*

Activity Type*

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External Conference Attendance - Type*

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External Conference Attendance - AAP - CME Type*

***Upload CME certificate in the "File Upload" field at the bottom.

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External Conf. Attendance - AAP - General EM hrs*

External Conf. Attendance - AAP-Peds/Peds EM hrs*

External Conf. Attendance - AAP-Trauma hrs*

External Conf. Attendance - AAP-Peds trauma hrs*

External Conf. Attendance - AAP-Stroke hrs*

External Conf. Attendance - AAP-Pain Mngmt hrs*

External Conf. Attendance - AAP-Other hrs*

External Conference Attendance - ACEP - CME Type*

***Upload CME certificate in the "File Upload" field at the bottom.

Select or enter value

External Conf. Attendance - ACEP - General EM hrs*

External Conf. Attendance - ACEP-Peds/Peds EM hrs*

External Conf. Attendance - ACEP-Trauma hrs*

External Conf. Attendance - ACEP-Peds trauma hrs*

External Conf. Attendance -ACEP-Stroke hrs*

External Conf. Attendance - ACEP-Pain Mngmt hrs*

External Conf. Attendance - ACEP-Other hrs*

External Conference Attendance - ACMT - CME Type*

***Upload CME certificate in the "File Upload" field at the bottom.

Select or enter value

External Conf. Attendance - ACMT - General EM hrs*

External Conf. Attendance - ACMT-Peds/Peds EM hrs*

External Conf. Attendance - ACMT-Trauma hrs*

External Conf. Attendance - ACMT- Peds Trauma hrs*

External Conf. Attendance -ACMT-Stroke hrs*

External Conf. Attendance - ACMT-Pain Mngmt hrs*

External Conf. Attendance - ACMT-Other hrs*

External Conference Attendance - CORD - CME Type*

***Upload CME certificate in the "File Upload" field at the bottom.

Select or enter value

External Conf. Attendance - CORD - General EM hrs*

External Conf. Attendance - CORD-Peds/Peds EM hrs*

External Conf. Attendance - CORD-Trauma hrs*

External Conf. Attendance - CORD- Peds Trauma hrs*

External Conf. Attendance -CORD-Stroke hrs*

External Conf. Attendance - CORD-Pain Mngmt hrs*

External Conf. Attendance - CORD-Other hrs*

External Conference Attendance - PAS - CME Type

***Upload CME certificate in the "File Upload" field at the bottom.

Select or enter value

External Conf. Attendance - PAS - General EM hrs*

External Conf. Attendance - PAS-Peds/Peds EM hrs*

External Conf. Attendance - PAS-Trauma hrs*

External Conf. Attendance - PAS- Peds Trauma hrs*

External Conf. Attendance -PAS-Stroke hrs*

External Conf. Attendance - PAS-Pain Mngmt hrs*

External Conf. Attendance - PAS-Other hrs*

External Conference Attendance-PNW PEM - CME Type*

***Upload CME certificate in the "File Upload" field at the bottom.

Select or enter value

External Conf. Attendance - PNW - General EM hrs*

External Conf. Attendance - PNW-Peds/Peds EM hrs*

External Conf. Attendance - PNW-Trauma hrs*

External Conf. Attendance - PNW- Peds Trauma hrs*

External Conf. Attendance -PNW-Stroke hrs*

External Conf. Attendance - PNW-Pain Mngmt hrs*

External Conf. Attendance - PNW-Other hrs*

External Conference Attendance-SAEM - CME Type*

***Upload CME certificate in the "File Upload" field at the bottom.

Select or enter value

External Conf. Attendance - SAEM - General EM hrs*

External Conf. Attendance - SAEM-Peds/Peds EM hrs*

External Conf. Attendance - SAEM-Trauma hrs*

External Conf. Attendance - SAEM- Peds Trauma hrs*

External Conf. Attendance -SAEM-Stroke hrs*

External Conf. Attendance - SAEM-Pain Mngmt hrs*

External Conf. Attendance - SAEM-Other hrs*

External Conference Attendance-OTHER- CME Type*

***Upload CME certificate in the "File Upload" field at the bottom.

Select or enter value

External Conf. Attendance - OTHER- General EM hrs*

External Conf. Attendance-OTHER-Peds/Peds EM hrs*

External Conf. Attendance - OTHER-Trauma hrs*

External Conf. Attendance - OTHER- Peds Trauma hrs*

External Conf. Attendance -OTHER-Stroke hrs*

External Conf. Attendance - OTHER-Pain Mngmt hrs*

External Conf. Attendance - OTHER-Other type hrs*

Life Support Certification Type*

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Life Support Certification - ACLS - Taught?*

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Life Support Certification - ACLS-Taught hrs*

Life Support Certification-ACLS-Gen. EM hrs*

***Upload ACLS certificate in the "File Upload" field at the bottom.

Life Support Certification-ATLS-Taught?*

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Life Support Certification -ATLS -Taught hrs*

Life Support Certification -ATLS -CME Type*

***Upload ATLS certificate in the "File Upload" field at the bottom.

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Life Support Certification -ATLS -Trauma Hrs*

Life Support Certification -ATLS -Peds Trauma Hrs*

Life Support Certification-BLS-Taught?*

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Life Support Certification -BLS -Taught hrs*

Life Support Certification -BLS -CME Type*

***Upload BLS certificate in the "File Upload" field at the bottom.

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Life Support Certification -BLS -Gen. EM Hrs*

Life Support Certification -BLS -Peds/Peds EM Hrs*

Life Support Certification-NRP-Taught?*

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Life Support Certification -NRP -Taught hrs*

Life Support Certification-NRP-Peds/Peds EM hrs*

***Upload NRP certificate in the "File Upload" field at the bottom.

Life Support Certification-PALS-Taught?*

Select

Life Support Certification -PALS -Taught hrs*

Life Support Certification -PALS -Peds/Peds EM Hrs*

***Upload PALS certificate in the "File Upload" field at the bottom.

Other CME activity - Brief description*

Please enter a brief description of the education activity that corresponds with the certificate you are uploading

Other CME activity - CME Type*

***Upload CME certificate in the "File Upload" field at the bottom.

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Other CME Activity - General EM hrs*

Other CME Activity - Pediatrics/Pediatric EM hrs*

Other CME Activity - Trauma hrs*

Other CME Activity - Pediatric Trauma hrs*

Other CME Activity - Stroke hrs*

Other CME Activity - Pain Mngmt hrs*

Other CME Activity - Other type hrs*

Procedure Logging Type*

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Procedure Logging - Intubation performed on:*

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Procedure Logging - Thoracostomy performed on:*

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Procedure Logging -Umbilical vein c. performed on:*

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Procedure Logging-Intraosseous line performed on:*

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Procedure Logging-Central venous l. performed on:*

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Procedure Logging-Needle cricothyro. performed on:*

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Procedure Logging-Ultrasound*

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Procedure Logging-Ultrasound Vascular access:*

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Procedure Logging-procedural sedation performed on*

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Proc. Logging-cardioversion/defibrillation perf on*

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File Upload

Please upload required CME certificates and Life Support Certification Documents.

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