01/2018
Arizona Board of Osteopathic Examiners In Medicine and Surgery
1740 W. Adams Street Suite 2410 Phoenix, Arizona, 85007
Ph : 480-657-7703 | Fx: 480-657-7715 | www.azdo.gov | questions@azdo.gov
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CME AUDIT REPORTING FORM
IF YOUR LICENSE NUMBER WAS RANDOMLY SELECTED FOR CME AUDIT OR YOU ARE REQUESTING AN EXTENSION,
YOU MUST REPORT YOUR CONTINUING MEDICAL EDUCATION ACTIVITIES SINCE YOUR LAST RENEWAL
In order to maintain a license to practice osteopathic medicine in the State of Arizona, you are required to complete forty (40) hours of CME during
the two calendar years preceding this renewal, meaning this year and last year (A.R.S. § 32-1825(B)). Twenty-four (24) of the forty (40) hours must
be AOA Category 1-A. The remaining balance of sixteen (16) CME may be any category including AMA Category 1.
1. Please complete the bottom portion of this form to identify the CME courses you completed since your last renewal. If you earned more than
forty (40) hours, you do not have to report the extra hours.
2. Attach documentation of CME: Accepted documentation -- your AOA CME Activity Report, your certifying board’s CME activity report, and
copies of Certificates of Completion for CME not otherwise accounted for on the CME Activity reports. CMEs obtained prior to this renewal cycle
will not be accepted.
Physician Name (Please print) ___________________________________________________________ License #_______________
RECORD OF CME ACTIVITY
Dates
M/D/YY
Name of CME Course/Activity # of Hours Category
I
attest that the above is a true and correct representation of the Continuing Medical Education that I completed since my last
renewal of licensure.
P
hysician Signature_______________________________________________________________ Date________________________
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