1. Complete this registration and evaluation form within 30 days of completing the activity.
2. Please save and email a copy of your completed evaluation to
3. Your certificate will be sent via email to the email address provided below.
4. For questions or concerns regarding the Program Evaluation or Certificate, the following contact methods are
available: EPC by email at
, or the EES Customer Service by phone at 1.877.EES.1331 Opt.5
Advanced Practice Nurse
Licensed Clinical Social Worker
Activity must be approved for the certificate type in order for such a certificate to be issued.
ACCME - Non Physician
EMAIL ADDRESS: Enter Complete Email Address
I assert that I attended 100% of this program:
Type your full name in the block above
PRIVACY ACT STATEMENT
AUTHORITY: Title 50, Appendix, U.S.C., Title 10, U.S.C., Public Law 96-357 96th Congress, September 24, 1980 (Amendment to 10 U.S.C.
PRINCIPAL PURPOSE(S): To develop policies and procedures, compile statistics and render analytical reports, and to track participation in
ROUTINE USES: The information provided on the application will be used to maintain data on EES activities, provide requested reports on
participation, and to provide activity original and duplicate certificates to EES activity participants.
AND VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL PROVIDING INFORMATION: Disclosure of information
requested in the EES registration form (the application) is voluntary; however, the information must be furnished in order to ensure the
applicant will receive a certificate of completion for EES activities and appropriate education credit.
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