Complete the form below and submit to SIU School of Medicine Office of Continuing Professional Development for processing. Date of teaching activity Faculty name Department Email address Phone Teaching format What was the format of the teaching activity? Who were your learners? Check all that apply. Medical students Residents Fellows Mentorship Scholarship Service Learning What was your role as teacher? Assessing performance Case development Instructing how to teach Instruction: clinical Instruction: research Instruction: skills building Formal presentation Mentoring Supervision: simulation Other… Enter other… Active Learning Describe what active learning you did to prepare for this teaching activity, including the learning resources used. Preparation Describe what active learning you did to prepare for this teaching activity, including the learning resources utilized. Improvement Describe how this learning will inform or improve your practice of teaching or your clinical practice skill set. (e.g. improved teaching skills, gained better understanding of pathophysiology, improved patient management strategies) Benefits Describe how this learning will inform or improve your practice of teaching or your clinical practice skill set. (e.g., improved teaching skills, better understanding of pathophysiology, improved patient management strategies). Competencies Competencies Clinical practice/patient care/procedural or technical skillsCommunication skillsMedical knowledgePractice-based learning/improvmentProfessionalismSystem-based practiceOther… Enter other… Which competencies might this learning assist with? Check all that apply. Barriers What barriers might you expect to encounter in implementing new knowledge/skills into your practice? Time spent How much time did you spend teaching? Please use quarter hour increments. Signature I attest the above information is correct. Accreditation The SIU School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The SIU School of Medicine designates this live activity for a maximum of 2 AMA PRA Category 1 CreditsTM per 1 hour of interaction with medical students and/or residents/fellows. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
