Continuing Education Credit Form

Primary Immunodeficiency Diseases: Diagnosis and Treatment.
 

The American Association of Colleges of Nursing will award 1.5 contact hours of continuing education (up to a total of 15 hours for the entire Bench to Bedside series) for viewing this tape/CD-ROM as an educational activity.  This Continuing Education Credit (CEC) Form must be submitted to verify you viewed the tape/CD-ROM and earned the credit. 

Steps

1.      Print this copy of the Continuing Education Credit Form

2.      View the videotape or CD-ROM

3.      Complete all information requested

4.      Copy the completed form for your records of contact hours earned.  No additional verification will be sent to you.

5.      Send original copy of completed form to:  CenterNet/HMTV,  529 14th Street, N.W., Suite 1292, Washington, DC 20045

Primary Immunodeficiency Diseases: Diagnosis and Treatment is part of the Bench to Bedside Video/CD-ROM Series for clinicians.  At the conclusion of this activity, the learner will be able to:
• Gain an awareness of primary immunodeficiency diseases.
• Describe different ways patients with primary immunodefciency diseases present clinically.
• Describe SCID and how to diagnose it.
• Explain the important aspects of making gene therapy for XSCID work.
• List the molecular causes of severe combined immunodeficiency.
• Explain how to diagnose this syndrome and identify what the best treatment option is.

(Please print)

 

Name________________________________________________ RN License # and state______________________
                        (Last)                         (M.I.)                        (First)

Address______________________________________________ City/State/Zip_____________________________

 

Date tape viewed______________ CE form printed on:    Signature  _____________________________

 

 

1.   Relationship to program purpose. Learning objectives for “Primary Immunodeficiency Diseases: Diagnosis and Treatment. ” support the overall purpose for which the series is designed.
___Yes   ___Partially   ___No
       

2.  Objectives   Has this program enabled you to have a better understanding of the objectives  listed above:
___Yes   ___Partially   ___No       

   

3.   Presenters

Please rate effectiveness of each presenter:

Rebecca H. Buckley, MD	_____Somewhat Effective	_____Effective	_____Very Effective
Jennifer M. Puck, MD	_____Somewhat Effective	_____Effective	_____Very Effective
Jerry A. Winkelstein, MD	_____Somewhat Effective	_____Effective	_____Very Effective

4.   Overall Program

Overall this educational activity was:   _____Marginal                       _____Good               _____Excellent

      Comments: