Steven Reames, Executive Director | 305 W Jefferson Boise ID 83702 | [email protected] | 208.336.2930
ACMS Physician Shadowing CME Program
Shadowing Physician Interest Form
GENERAL INFORMATION
Name:
Degree:
Practice Office Name:
Office Phone:
Applicant Email:
Office Manager Name:
Primary Specialty (AMA Specialties Only):
Secondary Specialty (AMA Specialties Only):
Gender: Male  Female 
Practice Office Address:
City
Zip:
Office Fax:
Office Manager Email:
NEED & LEARNING OBJECTIVES
Need:
After reflecting on my current practice, I have determined that, in order to provide better patient
care, I need to observe another provider’s patient communication interactions, and have the
opportunity to discuss their recommendations in this area.
________ Initials
General Objectives:


Observe new, and potentially unique, patient discussion techniques, history taking skills, and treatment
plan communication skills and strategies.
Discuss observations, and if appropriate, determine strategies for incorporating observed behavior and
recommendations into practice.
In addition to these general objectives, please list at least two learning objectives you have selfidentified that you hope participation in this activity will meet:
1.
2.
For any encounter I have as a result of participating in this activity, I will maintain the utmost patient/provider
relation confidentiality and attest to this.
Signature:
Date:
Please return form to: Ada County Medical Society, 305 W Jefferson St, Boise ID 83702
[email protected] OR FAX 208-336-3294 TEL 208-336-2930
ACMS Physician Shadowing CME Program
Shadowing Physician Reflection Form
In order to receive CME credit, completed form due two weeks after shadow session.
Dear Dr.
,
(insert Host Physician name)
My interest in spending time with you include:


Observing new, and potentially unique, patient discussion techniques, history taking skills, and treatment plan
communication skills and strategies.
Discussing observations, and if appropriate, determining strategies for incorporating observed behavior and
recommendations.
Insert self-identified objective prior to meeting

Insert self-identified objective prior to meeting

We saw:
1. (1st problem/disease)
during which I observed (takeaway from interaction).
2. (2nd problem/disease)
during which I observed (takeaway from interaction).
3. (3rd problem/disease)
during which I observed (takeaway from interaction).
4. (4th problem/disease)
during which I observed (takeaway from interaction).
When discussing these interactions, we determined the following recommendations/strategies that I can
incorporate into my patient interactions:
Additional comments about our shadow session:
Sincerely,
Dr.
(insert shadowing physician name)
Please return form by mail, fax or email to
Ada County Medical Society
305 W Jefferson St
Boise ID 83702
[email protected]
FAX 208-336-3294 TEL 208-336-2930
ACMS Physician Shadowing CME Program
Shadow Host Physician Interest Form
GENERAL INFORMATION
Name:
Degree:
Practice Name:
Office Phone:
Applicant Email:
Office Manager Name:
Primary Specialty:
Address:
Board Certification(s):
Expiration Date(s):
City
Zip:
Office Manager Email:
Secondary Specialty:
PRACTICE INFORMATION
Briefly describe the types of experiences/patient interactions you encounter in a typical four-hour
period:
Briefly describe your patient population:
Briefly describe typical conditions seen in your patient population:
Disclosure of Financial Relationships
A. Neither I, nor any member of my immediate family, have a significant financial interest in or affiliation
with any commercial supporter of this educational activity and/or with the manufacturer(s) of commercial
products and/or providers of any commercial services discussed in this educational activity.
B. I, or an immediate family member, have a significant financial interest in or affiliation with any commercial
supporter of this educational activity and/or with the manufacturer(s) of commercial products and/or
providers of any commercial services discussed in this educational activity.
C. I am a full-time employee of the commercial enterprise listed below.
Please list commercial enterprise and nature of relationship with each, e.g., research grants, stock or bond
holdings, speakers’ bureau, employment, ownership or partnership, consulting fees, other remuneration
(honoraria, travel expenses):
Commercial Interest(s)
Nature of Financial Relationship/Affiliation
Grant/ Research
Support
Consultant
Stockholder
Speakers
Bureau
Other
(Be Specific)
1.
2.
3.
4.
5.
Disclosure of Unlabeled/Investigational Uses of Products
A. The content of my material(s)/presentation(s) in this CME activity will not include discussion of
unapproved or investigational uses of products or devices.
B. The content of my material(s)/presentation(s) in this CME activity will include discussion of
unapproved or investigational uses of products or devices as indicated below:
I have read the Ada Canyon Medical Education Consortium policy on full disclosure. If I have indicated a significant
financial relationship, or if I will discuss unapproved or investigational uses of products or devices, I understand that I
am responsible for disclosing this information to participants at the beginning of my presentation/material. I
understand that failure to disclose or false disclosure may require the Ada Canyon Medical Education Consortium to
identify a replacement for my participation.
Signature:
Date:
Please return form to: Ada County Medical Society, 305 W Jefferson St, Boise ID 83702
[email protected] OR FAX 208-336-3294 TEL 208-336-2930