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EMAs in shortfall for continuing competence requirements should complete this form to request adjudication. Please make sure that you submit your supporting documentation along with the form.
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Summary of Adjudication Request

Outline the details of the course content and what skills and/or knowledge were obtained from the continuing education activity submitted for adjudication below.

  • Include the course provider, name of activity, date, duration, location, and certificate of completion.
  • If submitting a conference, include a copy of the agenda with the breakdown of sessions and their content, and your verification of attendance.
  • For patient contacts, please provide the date, location, your role, patient chief complaint or type of contact, and the skills performed for the patient for each contact submitted.
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Attach Your Supporting Documentation

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HLTH 3735  Rev. 2023/01/18
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0e315d36060109ba910213213685404c231760df
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