The Academy of Medicine of New Jersey

Roving Symposia Registration

Roving Symposia are designated Category 1 activities and apply toward fulfillment of requirements set forth by the AMA Physician's Recognition Award. Topics not included on the Roving Symposia Topic List will be considered with appropriate Justification.

Please note that each program has a registration fee payable to the Academy to offset honoraria and other administrative expenses. Fees for an Individual Roving Symposium are:

Institutional Members - $500.00
Non-Member Organizations - $600.00

To Register Online

For your convenience, requests for Roving Symposia may now be submitted online using the Registration Form below. When submitting requests online, please print out the confirmation page and mail it with the applicable fee to AMNJ at the address below.

To Register by Mail

The Roving Symposia Registration and Justification Form may also be submitted by mail. You will need Adobe Acrobat Reader version 4 or above to access the printed form. If you don't have Acrobat Reader installed on your computer, you can download it for free at Adobe.com.

Click here for the printed registration form. Acrobat Reader will open and display the form on your screen. To print the form, click the Print button on the Acrobat Reader toolbar.

Mail the completed registration form with the applicable fee to:

The Academy of Medicine of New Jersey
Attention: Coleen Hampson, Program Specialist
Two Princess Road, Suite 101
Lawrenceville, NJ 08648

For additional information email Coleen Hampson, Program Specialist, or telephone (609) 896-1901.

Roving Symposium Registration Form

Hospital/Agency:

Mailing Address:

City, State, Zip:

Director of Medical Education or Person Responsible for CME:

In my absence please contact:

Telephone:

FAX:

Topic Selection (Each Selection Must Have a Separate Form):

Date (Month/Day/Year):

Time: AM PM

Symposium Location:

Moderator:

Hospital Title/Position of Moderator:

Justification for Roving Symposium Selections

Needs Assessment:

Please identify the process used to determine your institutions need for this topic. Each selection must have a separate form.

Request by staff physician, facility, department head, or planning committee.

Survey of medical staff by survey questionnaire.

Review of evaluation forms from previous programs.

Data obtained from hospital audits, quality management, risk management, infection control or other staff committee.

Identify Committee:

Other (Please identify):

Objectives:

Upon completion of this symposium, participants should be able to: