Group Training for Smart Rx Sign in Sheet

Please use this form to track attendance for group presentations for the Smart Rx training. Unfortantely for group presentations, CME is not included. If individuals want CME, they must register and watch the Smart Rx training individually and complete the CME requirements at the end of the presentation.

Question Title

* 1. Date of Smart Rx Presentation:

Date / Time

Date

Question Title

* 2. System?

Question Title

* 3. Hospital:

Question Title

* 4. Attendee List: Please include the information below for each attendee.

Last Name, First Name

Prescriber type- Physician, APP, Resident, Other

Last Name, First Name

Prescriber type- Physician, APP, Resident, Other

Last Name, First Name

Prescriber type- Physician, APP, Resident, Other

Last Name, First Name

Prescriber type- Physician, APP, Resident, Other

Last Name, First Name

Prescriber type- Physician, APP, Resident, Other

Last Name, First Name

Prescriber type- Physician, APP, Resident, Other

Last Name, First Name

Prescriber type- Physician, APP, Resident, Other

Last Name, First Name

Prescriber type- Physician, APP, Resident, Other

Last Name, First Name

Prescriber type- Physician, APP, Resident, Other

Last Name, First Name

Prescriber type- Physician, APP, Resident, Other

Question Title

* 5. Do you need to enter more attendees?

Yes

No