This form must be completed and returned and an evaluation form completed online in order to earn nursing contact hours.
Please mail or fax the attendance form to:
Michigan Center for Rural Health; 909 Fee Road; B-218 West Fee Hall; East Lansing, MI 48824
(517) 432-0007 – Fax
Email:
Co-sponsored by: MSU College of Nursing & Michigan Center for Rural Health, MDCH Oral Health Program
Program: Trans-Oral Robotic Surgery and Free Tissue Reconstruction in Head and Neck Surgery
Nursing Grand Round Date: September 15, 2017 Speaker: Tamer Ghanem, MD and Steven Chang, MD
Nursing Contact Hours are awarded for attendance and participation for the entire program. At the end of the program you will have earned 1.0 continuing nursing education contact hours.
Please note: Your certificate will be emailed to you in approximately 6-8 weeks.
Site attended (required) ______County ______
Name: ______
Organization Name ______
Work Address ______
City ______State ______Zip______
Day Phone: ______E-mail Address: ______
(required for certificate)
_____ I have attended the entire program. I understand that I must also complete an evaluation online in order
to receive a certificate.
Participant signature (required)______
To complete the required evaluation online – go to: https://www.surveymonkey.com/r/Evaluation_Sept_15_2017.
by September 29, 2017 . Thank you!
Michigan State University College of Nursing (OH-294, 08/1/18) is an approved provider of continuing nursing education by the Ohio Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.