Oral Health Grand Round – Attendance Record
In order to receive continuing education credit, this form must be completed and returned along with the evaluation form to:
Michigan Center for Rural Health Office
B-218 West Fee Hall
East Lansing, MI 48824
Fax: (517) 432-0007
Email:
Program Title: Trans-Oral Robotic Surgery and Free Tissue Reconstruction in Head and Neck Surgery
Program Date: September 15, 2017; 12-1 pm EST
Program Presenters: Tamer Ghanem, MD and Steven Chang, MD
Program presented by: MDHHS Oral Health Program, Michigan Center for Rural Health
Continuing Education hours –Upon successfully returning attendance and evaluation form (complete online) by September 29, 2017 https://www.surveymonkey.com/r/Evaluation_Sept_15_2017.
and you will be able to earn 1.0 continuing education credit.
This program is accredited by the Michigan Center for Rural Health (MCRH) is an approved Board of Dentistry (MBOD) Provider Program - #299150014. This approval is valid from April 2011 through November 2018.
IDENTIFICATION (Please PRINT legibly)
Name: ______
Organization: ______
Address ______
City ______State ______Zip______
Day Phone: ______
E-mail Address: ______
(Required for certificate)
State license number (required) ______
Participant Required Signature
I verify that I have attended the entire program and have completed a program evaluation.
Please note that you must have an individual verify (by signing below) that you attended the entire program. This individual can be a co-worker.
Sign in time: ______Sign out time: ______
Participant signature ______
Monitor Required Signature
I verify that the above participant did attend the entire program.
Monitor signature ______