Ohio AAP CME Evaluation - INSERT ACTIVITY TITLE

INSERT ACTIVITY TITLE

Question Title

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* 1. Please provide your contact information:

Name:

Company:

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address: *

Phone Number:

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* 2. Are you a(n):

Attending Physician

Fellow in Training

Resident in Training

CNP/RN

Medical Student

Other (please specify):

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* 3. Specialty:

Primary Care

Medical Sub-specialty

Surgeon

Hospitalist

Urgent Care

Other (please specify):

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* 4. How can the Ohio AAP assist in meeting your education needs?