Roster of Rn's Who Completed the Activity

ROSTER OF RN'S WHO COMPLETED THE ACTIVITY

Georgia Immunization Office

Department of Public Health

This form must be completed and retained by Provider for 6 years.

TITLE OF ACTIVITY: Epidemiology and Prevention of Viral Hepatitis from A-E: An Overview__

Educational Activity: #_162-13_____

LOCATION: ______

DATE GIVEN: ______GNA APPROVED CONTACT HOURS: 3.0

PROVIDER/COPROVIDER: Georgia Immunization Program 404-657-3158

CONTACT PERSON / NURSE PLANNER: Lynne Mercedes / Janet McGruder

ROSTER OF ATTENDEES

Please print or type Registered Professional Nurses Only

NAME
Last Name, First / # Contact hours if different from above / ADDRESS / VFC PIN # /

Vaccine Administration

Educational Activity: #_162-13____