Ce Credit Request Form

MIDWEST PHARMACY RESIDENTS CONFERENCE

CE CREDIT REQUEST FORM

Please complete this form if you have registered to receive CE credit. At the end of the conference, return this form in the box marked "CE Forms".

Name______(please print)

Institution ______

Phone ______Email ______

You may receive credit for only one session in each of the numbered groups below. Also, you must attend the entire session and fill out evaluation forms on all speakers in that session. For example, during the 1:00-3:00 time period on Friday, there are six sessions (2a-2f). You may only get CE credit for one of those sessions. Please put your initials beside the one session you attended during each time frame.

Fri, May 8, 9:15-11:45/9:45-11:15 InitialsFri, May 8, 1:00-3:00 Initials

1a. Critical Care ______2a. Critical Care ______

1b. Primary Care ______2b. Primary Care ______

1c. Internal Medicine ______2c. Pediatrics ______

1d. Clinical Services ______2d. Clinical Services ______

1e. Community ______2e. Infectious Disease ______

1f. Pharmacy Practice ______2f. Hematology ______

1g. Pediatrics ______

1h. Hematology ______

Fri, May 8, 3:45-5:45/4:15-5:45 InitialsSat, May 9,8:00-10:30 Initials

3a. Critical Care ______4a. Infectious Disease ______

3b. Primary Care ______4b. Pharmacy Practice ______

3c. Pediatrics ______4c. Internal Medicine ______

3d. Clinical Services. ______4d. Cardiology ______

3e. Infectious Disease ______4e. Pharmacy Practice ______

3f. Hematology ______4f. Community ______

3g. Clinical Services ______4g. Cardiology ______

3h. Critical Care ______4h. Pharmacy Practice ______

4i. Internal Medicine ______

Sat, May 9, 11:00-1:00 InitialsSat, May 9,2:00-4:00/2:00-4:30 Initials

5a. Critical Care ______6a. Critical Care ______

5b. Primary Care ______6b. Primary Care ______

5c. Internal Medicine______6c. Infectious Disease ______

5d. Primary Care ______6d. Critical Care ______

5e. Infectious Disease ______6e. Infectious Disease ______

5f. Primary Care ______6f. Primary Care ______

5g. Infectious Disease ______6g. Clinical Services ______

5h. Critical Care ______

5i. Pharmacy Practice ______

When complete, please return form to box marked "CE Forms".