Continuing Education Program Approval Form For Program Attendees - Minnesota Board Of Pharmacy
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1Name and address to where reply should be sent:
FOR OFFICE USE ONLY:
___________________________
License # ______
Approved _____ hrs. CE Credit
_____________________________________________
By: ________
__________________
_____________________________________________
Continuing Education Advisory
Date Received
Task Force
MINNESOTA BOARD OF PHARMACY
2829 UNIVERSITY AVE SE #530
Minneapolis, MN 55414-3251
Phone: (651) 201-2825
Fax: (612) 617-2262
E-mail: pharmacy.board@state.mn.us Web:
CONTINUING EDUCATION PROGRAM APPROVAL FORM FOR PROGRAM ATTENDEES
Directions: Please fill out this form for obtaining approval of the previously unapproved program you attended.
To receive credit your completed form should be submitted to the Board of Pharmacy within 90 days of your attendance.
1. Program Data
A. Program Title: ______________________________________________________________________________
B. Program Site: _______________________________________________________________________________
C. Program Date: ______________________________________________________________________________
D. Credit Hours Requested (#): _______
E. Program Type (seminar, study group, etc.): _________________
2. Title and address of major sponsoring organization:
Name: _______________________________________________________________________________________
Street Address: _______________________________________________________________________________
City/State/Zip: ________________________________________________________________________________
3. List any multiple sponsors:
Person responsible for the CE
Program
Address
Telephone:
___________________________
________________________________________
_________________
___________________________
________________________________________
_________________
___________________________
________________________________________
_________________
4. Evaluation:
A. Describe the methods employed for participants to assess their achievement of the objectives stated in the
program brochure or announcement.
_______________________________________________________________________________________________
B. Describe the methods used for you as an attendee to provide feedback to the provider on the program or its
presentation.
________________________________________________________________________________________________
5. Please attach a copy of the program announcement, if available.
6. Please send a copy of the program outline.
7. Please send a copy of the Certificate of Attendance.
___________________________________________________________________
_________________
________
(Name and Title of Person completing this form.)
(Telephone #)
(Date)
Please send this completed form to the address shown above.
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