CPL Event Registration Form

The University of New Mexico School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The University of New Mexico School of Medicine designates this live activity for a maximum of 2.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Thank you for your interest in this CPL offering. This form has two parts.

Part One requests demographic information and describes any registration fees associated with this event. This page must be completed in order for your registration to be confirmed.

Part Two is optional and requests information which assists CPL in better understanding the reasons for your interest, and in evaluating our program offerings and marketing methods for improvement. Please answer all questions and click the "Submit" button at the end of the form to ensure a complete registration.

Teaching with Limited Time while Providing Patient Care in the Outpatient Setting

Registration Fee:

UNM/HSC Employee $160

Non-UNM/HSC Employee $195

First Name*

As you would like it to appear on your attendance certificate:

Last Name*

As you would like it to appear on your attendance certificate:

Degree(s):*

Position Title*

The category that best describes my Position Title is:

Select or enter value

If other please specify:

UNM NetID: Please provide if applicable.*

(This information is available as the last line in your UNM Directory listing.)

School/College Affiliation*

Select or enter value

Department*

Please add your department (example: Internal Medicine, Pediatrics, etc.). If you are not affiliated with UNM/HSC please write "None."

Email Address*

(If a UNM/HSC employee, please provide your @Salud or @ UNM address):

Business Phone Number*

Phone

If you are not affiliated with UNM/HSC, please provide the following information:

Company Name

Business Address

City

State

Zipcode

Country if not USA

Payment Type*

Please select from the list below:

Select or enter value

Registration fees for this event are as follows:

Regular UNM/HSC Employee (Faculty/Staff)

1. Tuition Remission Benefit

Upon submission of this registration form, you will receive an email with additional workshop information.

THIS SECTION FOR EMPLOYEE PROFESSIONAL DEVELOPMENT

NOTE: Tuition Remission is applicable to benefits eligible employees as defined in Section 2.2 of UAP 3700, "Education Benefits"

UNM Banner ID Number*

EMPLOYEE CERTIFICATION:*

I acknowledge that I have reviewed UAP 3700, “Education Benefits” and certify this request for Tuition Remission Benefit is within the maximum allowable benefit per semester as provided in the Policy.

I understand that I am responsible to repay all costs that exceed the maximum allowable benefit. I acknowledge the University will bill me for any excess tuition costs that have been paid. If the bill is not paid, UNM may collect any excess through payroll deductions

I acknowledge that the amount of tuition benefits for certain courses are considered taxable under current published IRS regulations. I understand that any taxable tuition benefit I receive will be added to my wages as taxable income and will be subject to income tax withholding.

Additionally, I understand that if the amount of tuition benefits I receive during the calendar year exceeds the published IRS maximum amount, the amount in excess of the IRS maximum will be added to my wages as taxable income and will be subject to income tax withholding.

Information regarding Tuition Rates and the Taxability of Tuition Remission my be viewed at: http://bursar.unm.edu/index.html

Check here to indicate that you acknowledge each of the above statements.

Employe Signature*

Check here to indicate that you have read and agree to the terms of the the UNM Employee Tuition Remission Benefit Form.

Tuition Remission Eligible*

Please be advised that by accessing this module, you acknowledge that you are entitled to utilize your tuition remission benefits. However, if you have any holds or are deemed ineligible, it will be necessary to submit payment in order to obtain CME credit.

Supervisory approval is required if any of the following apply:

•A credit course taken during the employee’s regular work schedule (approval is to authorize the absence from work and to approve an alternate work schedule); or

•A non-credit professional development course taken during the employee’s work schedule that is related to the employee's job or a UNM job to which the employee may reasonably aspire (approval is to authorize absence from work and approve an alternate work schedule); or

•A non-credit health and fitness course taken during the employee’s work schedule (approval is to authorize the absence from work and to approve an alternate work schedule).

If you require supervisory approval based on the list provided above, kindly submit the form.

To obtain the tuition remission form, please copy and save the link below. This form requires appropriate supervisory approval before submission. Once completed, email the form to the Office for Continuous Professional Learning (CPL) at HSC-cpl@salud.unm.edu.

https://hsc.unm.edu/medicine/education/cpl/_cpl-docs/em-763-limited-time-tr_fillable-1.pdf

Please get in touch with CPL if you have any questions regarding the tuition remission form.

Do you need to request supervisor approval?*

Select or enter value

Registration fees for this event are as follows:

UNM/HSC Employee or Non/UNM HSC Employee

2. Credit Card or Debit Card

Upon submission of this registration form, you will receive an email with additional workshop information and instructions regarding remitting payment.

I am attending this workshop because:

The workshop material or technology is new or interesting to me.

(1= Strongly Disagree, 2 = Disagree, 3 = Neither Agree or Disagree, 4 = Agree, 5 = Strongly Agree)

The module provides training on concepts or skills related to personal goals.

(1 = Strongly Disagree, 2 = Disagree, 3 = Neither Agree or Disagree, 4 = Agree, 5 = Strongly Agree)

This workshop has been recommended by a colleague.

(1 = Strongly Disagree, 2 = Disagree, 3 = Neither Agree or Disagree, 4 = Agree, 5 = Strongly Agree)

This module fulfills a requirement within the Achievement in Medical Education Program (AMEP).

(1 = Strongly Disagree, 2 = Disagree, 3 = Neither Agree or Disagree, 4 = Agree, 5 = Strongly Agree)

Please elaborate or describe any other reason you have for attending this event:

If "other", please describe:

Send me a copy of my responses

Privacy Notice|Report Abuse

Teaching with Limited Time while Providing Patient Care in the Outpatient Setting

If you are not affiliated with UNM/HSC, please provide the following information:

Registration fees for this event are as follows:

THIS SECTION FOR EMPLOYEE PROFESSIONAL DEVELOPMENT

Supervisory approval is required if any of the following apply:

Registration fees for this event are as follows:

Sponsored SOM

I am attending this workshop because: