CMEO JP Final Report Form | 2021 | Winter Course in Infectious Diseases-Grant Downing

The Final Report form and supporting documentation are due to CME Outfitters no later than 4 months after the conclusion of a live/internet live activity. For enduring activities, the Final Report form and supporting documentation are due annually, no later than January 31 of each year it is active. Thank you.
Name*
First Last
Joint Provider Name*
Organization/Company Name
Email*
Best phone number to reach you*
Activity Date/Title:

Attendance
Please enter for the number of learners for each applicable profession. If a profession below does not apply to the activity, please leave blank.
Nurses
Optometrists
Pharmacists
Physician Assistants
Physicians
Psychologists
Social Workers
Dietitians
Athletic Trainers
Other

Evaluation Data
Evaluation Data*
- I attest that CME Outfitters managed the evaluation form for this activity. I will submit activity attendance data for this activity to CME Outfitters.
- I attest that my organization managed the evaluation form for this activity. I will submit all evaluation and attendance data for this activity to CME Outfitters.
Number of Evaluation Respondents

Financial Summary
CMEO is required to provide an income and expense statement that records the collection and disbursement of all commercial support. Please provide a budget that includes the following components (if applicable) for each activity or project. The grant reconciliation section must be completed for all grants received in support of the educational activity.
Income
Total Registration Fees
Total Exhibits
Total Other Commercial Promotion (“Marketing Support” – ads, satellite symposia, etc)
Total Government Monetary Grants
Total Government Monetary Grants
Total Private Monetary Donations
Total Government Monetary Grants
Total Miscellaneous Income
Total Commercial Support (“Educational Grants” – monetary and in-kind) (Letters of Agreement required)
Please list Commercial Supporter Names, Amount Awarded, Date of Executed Letter of Agreement
Expenses
Total Honoraria
Total Logistics
Total IT (Information Technology)
Total Marketing
Reconciliations to Supporters
Grant Reconciliation – Required if your activity received Commercial Support (“Educational Grants”)
Attestation*
I attest that the above information is correct as of date of submission.
Supporting Documentation*
I will submit all evaluation and attendance data to CME Outfitters to complete the JP Final Report process
Date of submission*
MM slash DD slash YYYY
Signature*

Attendance