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Institute for Translational Sciences - Education Office |
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present
the course |
Clinical
Research: Tools and Techniques 2009-2010
The
purpose of this registration form is to ensure desired credit or certification
of attendance, for the course, is provided for all participants. A letter documenting
attendance will be provided to the participant or his/her training supervisor.
Return Completed
form to: ITS-Education Office
ITS Education - UTMB Route 0266; Fax (409) 772-8097; Phone (409) 772-1484 creo.utmb@utmb.edu
(Please print or type):
Last Name______________________________ First Name___________________________ Degree________
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c
UTMB - Employee or Student # (required for Web CT access) |
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Position: (Faculty, Fellow, Resident, Staff, Student, etc.) |
| Department/School: |
| Division/Area: |
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Supervisor: (For Fellows, Residents, Student, and others in training) |
| Campus Mail Route: __ __ __ __ |
| Work Phone Extension: __ -- __ __ __ __ |
Registration Fees:
|
[_] |
Clinical Research: Tools and Techniques |
$50.00 |
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|
[_] |
CME credit (Optional) |
$50.00 |
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Total
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$________ |
Method
of Payment:
[_] Check enclosed, made payable to “UTMB – ITS Education Office”
[_] Interdepartmental Transfer from:
FRS
Account Number: ________________________
Billing Contact Person:
________________________
Billing Contact
Extension: _______________________
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I plan to attend (check all that apply): |
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|
____ Skills & Methods Module I (Aug. 10 to Oct. 5 & Jam. 4 - Feb. 1) |
____ Epidemiology & Statistics Module (Feb. 8 to May 17) |
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____ Regulations/Ethics Module II (Oct.12 to Dec. 14) |
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Signature ______________________________ Date ____/____/______
Please return this form to ITS Education, Route 0266 or Fax 2-8097
This course is part of the
Institute for Translational Sciences Education Program, which is partially supported
by a grant from the National Institutes of Health
UL1RR029876