OOA - CME 1C Credit Application

CME 1C Credit Application

This form should only be completed by osteopathic physicians who are requesting the reclassification and approval of CME activities from Category 2 to Category 1-C. Any D.O. who has obtained forty (40) hours or more of credit approved for osteopathic categories 1-A and 1-B should not file this form. There is a $25 charge to convert all credits listed on this application.
Select Fee Amount:
Name
Address
City State Zip
Phone
Email
Ohio DO License
Specialty
SECTION 1 - Request for Category Reclassification
I hereby request that the following programs, which are not approved for osteopathic CME Category 1-A or 1-B be certified in Category 1-C by the Ohio Osteopathic Association's Committee on Professional Affairs for the purpose of Ohio licensure. A copy of certificate or transcript is required.
Activity
Location
Date(s)
Category
Credit Hours
Activity
Location
Date(s)
Category
Credit Hours
Activity
Location
Date(s)
Category
Credit Hours
Activity
Location
Date(s)
Category
Credit Hours
Activity
Location
Date(s)
Category
Credit Hours
SECTION 2 - Reason(s) for Requesting Reclassification
The reasons for making this request are: (Check all that apply)
Circumstances require that I attend CME programs near my home and similar osteopathic programs are not available in Ohio or in the geographical area where I practice, that are relevant to my practice.
I am/was in a non-osteopathic internship, residency or fellowship program which is/was NOT approved by the American Osteopathic Association. (If checked, please complete Section 3)
The courses sponsored by osteopathic organizations are not relevant to my practice in terms of subject matter because of my specialty:
Other reasons for request:
SECTION 3 - Credit for Residency or Fellowship Training while Licensed
If you are seeking CME Credit for an AOA or ACGME residency or fellowship program, please list program(s) that you wish to have approved. The State Medical Board of Ohio will accept 50 category 1 credits for each year of residency/fellowship completed in an approved AOA or ACGME program. A copy of your certificate of completion or letter from your program director is required.
Please check one: Residency Fellowship
Specialty
Hospital
City, State
Program Director
Start Date
Completed
   - denotes required fields