Download ABIM Knowledge Module Order Form

Learning Session
Medical Knowledge Module Order Form
Directions: Please provide the following event information and indicate the Medical Knowledge Module(s) you would like to
present at your upcoming Learning Session. Time-limited licensing of an ABIM Medical Knowledge Module is $250 per module per
use. Use may be a single session or multiple sessions within one conference; Learning Sessions held after the time indicated on
this form constitute another use of the module, and a new form should be submitted. If you plan to host more than one session,
you may find it helpful to complete and submit a separate form for each one. Please submit all completed order forms to SelfAssessment Product Manager Marni C. Grambau at [email protected] or fax to 215.446.3570.
The module(s) in PDF form and in PowerPoint form, as well as printed materials for the session(s), will be mailed approximately 90
days in advance of the Learning Session. Please submit this form at least 90 days prior to your scheduled session.
The American Board of Internal Medicine appreciates your commitment to lifelong learning and the valuable enrichment that you
offer to ABIM diplomates by hosting a Learning Session.
Learning Session Information
A.
Organization Name:
Organization Address:
Administrative Contact Name and Contact Information:
Has your organization previously held a Learning Session?
How did you hear about ABIM Learning Sessions?
B.
Event Name:
(e.g., Chapter Meeting, Annual Conference, Faculty Development Course)
Event City/State:
Event Classroom/Bldg:
Event Date(s) and Time(s):
ABIM Medical Knowledge Module(s) to be utilized during Learning Session:
(List of available modules is included in this document. Please check those boxes in addition.)
Approximate number of anticipated Learning Session participants:
If number of attendees is per session, total attendees:
C.
Is your organization granting CME credits to Learning Session participants?
If so, how many CME credits?
Will your organization charge a participant fee?
If so, what is the fee per participant?
Facilitator Information
(You may provide complete facilitator information on a separate page if needed.)
Name:
Phone:
Email:
Name:
Phone:
Email:
Website Information
Please list our organization’s URL address on ABIM’s website for participants to access more information about
our upcoming Learning Session. URL: http://
Please do not list our organization's scheduled learning session on ABIM's website; learning session is for our
organization's faculty members only
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Medical Knowledge Modules Available
Please indicate the ABIM Medical Knowledge Module(s) to be utilized during your Learning Session(s) by checking
the box(es) below. The 2007, 2008, and 2009 Update Modules contain 25 multiple-choice questions worth 10 points
toward Maintenance of Certification; and the Clinical Skills Module contains 60 multiple-choice questions worth 20
points toward Maintenance of Certification. For more information about ABIM’s Maintenance of Certification
Program, visit www.abim.org.
Cardiovascular Disease, 2007 Update (A1-E)
Cardiovascular Disease, 2008 Update (A1-F)
Cardiovascular Disease, 2009 Update (A1-J)
Clinical Cardiac Electrophysiology, 2007 Update (B3-E)
Clinical Cardiac Electrophysiology, 2008 Update (B3-F)
Clinical Cardiac Electrophysiology, 2009 Update (B3-J)
Clinical Skills (86-A)
Critical Care Medicine, 2007 Update (A2-E)
Critical Care Medicine, 2008 Update (A2-F)
Critical Care Medicine, 2009 Update (A2-J)
Endocrinology, 2007 Update (A3-E)
Endocrinology, 2008 Update (A3-F)
Endocrinology, 2009 Update (A3-J)
Gastroenterology, 2007 Update (A4-E)
Gastroenterology, 2008 Update (A4-F)
Gastroenterology, 2009 Update (A4-J)
Geriatric Medicine, 2007 Update (B1-E)
Geriatric Medicine, 2008 Update (B1-F)
Geriatric Medicine, 2009 Update (B1-J)
Hematology, 2007 Update (A5-E)
Hematology, 2008 Update (A5-F)
Hematology, 2009 Update (A5-J)*
*Available in May 2009
IM- Office Based, 2007 Update (C0-D)
IM- Office Based, 2008 Update (C0-F)
IM- Office Based, 2009 Update (C0-J)
IM- Hospital Based, 2007 Update (A0-E)
IM- Hospital Based, 2008 Update (A0-F)
IM- Hospital Based, 2009 Update (A0-J)
Interventional Cardiology 2007 Update (B2-E)
Interventional Cardiology 2008 Update (B2-F)
Interventional Cardiology 2009 Update (B2-J)
Medical Oncology, 2007 Update (A8-E)
Medical Oncology, 2008 Update (A8-F)
Medical Oncology, 2009 Update (A8-J)*
*Available in May 2009
Nephrology, 2007 Update (A7-E)
Nephrology, 2008 Update (A7-F)
Nephrology, 2009 Update (A7-J)
Pulmonary Disease, 2007 Update (A9-E)
Pulmonary Disease, 2008 Update (A9-F)
Pulmonary Disease, 2009 Update (A9-J)
Rheumatology, 2007 Update (B0-E)
Rheumatology, 2008 Update (B0-F)
Rheumatology, 2009 Update (B0-J)
Infectious Disease, 2007 Update (A6-E)
Infectious Disease, 2008 Update (A6-F)
Infectious Disease, 2009 Update (A6-J)
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