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Please provide the following contact information for the Course Director.
Course Director *
Work Phone *
Please provide the following contact information for the Department Coordinator.
This activity is affiliated with: *
UTMB Galveston Affiliation
UT Houston Affiliation
Entity submitting overview (Department, company, society, institution):
that this activity addresses. Please include a minimum of one published source to support the gaps identified:
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Start Date: (mm/dd/yyyy)
End Date: (mm/dd/yyyy)
Projected number of participants: *
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(Hold Ctrl and click to select multiple options) *
Tentative CE Hours:
Event Type: *
Community Hospital Event