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SSW/AHEC Training CPD Request Form – Confirmed Program

Once a program is confirmed with a speaker, this form is to be sent to the SSW/AHEC Liaison with the details of the program. This form is very helpful to the SSW/AHEC Liaison in keeping track of confirmed programs.

[form]

 

 

AHEC Confirmed Training: _____________________________________________________________

AHEC Contact Person: _________________________________________________________________

Location of Training (include County): ____________________________________________________

SSW/AHEC Training Faculty/Consultant Confirmed: ____________________________________________________________________________________

Confirmed Program Title: _______________________________________________________________________

Date of Confirmed Program: ____________________________________________________________________________________

____________________________________________________________________________________

Number of Contact Hours: ______________________________________________________________

Format (Virtual/Hybrid/In-Person): ________________________________________________________

Other Important Details: