SGMP Education Contact Hour Approval Request

Please submit form 30 days prior to monthly education program

Question Title

* 1. Chapter

Question Title

* 2. Request for Contact Hour Approval

Submitted by

Contact Email

Contact Telephone Number

Date of Request

Date of Program

City/Town

State

Zip

Question Title

* 3. Program Format

Face to Face

Live Webinar

Recorded Webinar

Hybrid

Question Title

* 4. Title of Presentation

Question Title

* 5. Core Competency

Question Title

* 6. Speaker Name and Title

Question Title

* 7. Length of Program

90 Minutes - 1.5 Contact Hours

60 Minutes - 1 Contact Hour

30 Minutes - .5 contact hours

Comments

Question Title

* 8. Brief Description of Program

Question Title

* 9. Please list three (3) learning objectives or "take-aways" from your presentation

Take-Away 1

Take-Away 2

Take-Away 3

Question Title

* 10. Can this program be posted in the Chapter Tool Box

Yes

SGMP Education Contact Hour Approval Request

Please submit form 30 days prior to monthly education program

Question Title

* 1. Chapter

Question Title

* 2. Request for Contact Hour Approval

Question Title

* 3. Program Format

Question Title

* 4. Title of Presentation

Question Title

* 5. Core Competency

Question Title

* 6. Speaker Name and Title

Question Title

* 7. Length of Program

Question Title

* 8. Brief Description of Program

Question Title

* 9. Please list three (3) learning objectives or "take-aways" from your presentation

Question Title

* 10. Can this program be posted in the Chapter Tool Box

Question Title

* 11. Additional Information (if Applicable)

Question Title

* 12. Approval - FOR DIRECTOR OF EDUCATION USE ONLY