Health Center, Clinic, Organization Or Research Study

2011 STD Update

October 13th, 2011

Registration Form

Send completed forms to:

STD Screening Program, 356 7th Street, San Francisco, CA 94103

Email:

Fax: (415) 487-5581Phone: (415) 487-5515

Last Name:

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First Name:

Title:

Health Center, Clinic, Organization or Research Study:

Work address: Street and Number

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City

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ZIP code

Phone:

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Email address:

Continuing Education

There is a fee for participants requesting continuing education units.

I am not requesting continuing education units
I am a physician requesting CMEs
Check payable to: San Francisco Mental Health Education FundFee: $20.00 /

License #

I am a nurse, social worker, or health educator requesting CEUs
Check payable to: San Francisco Public Health FoundationFee: $15.00
I am an San Francisco Department of Public Health employee (fee waiver eligible) /

License #

/ This is an activity offered by Community Behavioral Health Services (CBHS), a CMA accredited provider. Physicians attending this course may report up to 3 hours of Category 1 credits toward the California Medical Association’s Certification in Continuing Medical Education and the American Medical Association’s Physician’s Recognition Award. (CME application pending)
The San Francisco Department of Public Health, Community Health Education Section has been designated as a provider of continuing education for nurses, social workers and health educators. The California State Board of Registered Nursing has approved the San Francisco Department of Public Health-Community Health Education Section-Code, as a Provider of Continuing Education for Registered Nurses provider # CEP 03548. The California Board of Behavioral Sciences has approved the San Francisco Department of Public Health-Community Health Education Section-Provider #1389, as a Provider of Continuing Education for MFCC, MFT, and LCSW’s. The Community Health Education Section and the San Francisco Department of Public Health has been designated as a multiple event provider of continuing education by the National Commission for Health Education Credentialing, Inc., Provider # CA0039.