AGEC Program Sign-in Sheet for Contact Credit Hours Question Title * 1. Program Affiliation (select from drop down menu) CHES Dietetics First Responder Long Term Care (LTC)/ Nursing Home Administrator MD Nursing Pharmacy Physical Therapy/Occupational Therapy Social Work Speech Pathology Student Other Other (please specify) Question Title * 2. Program Title Question Title * 3. Date and Time IN Date / Time IN Date Time AM/PM - AM PM Question Title * 4. Time Out Time Out Time AM/PM - AM PM Question Title * 5. Participant Sign-in Information Name Professional Suffix (e.g., MD, DO, RN, RD, PA, PT, PharmD, etc.) For CHES credit hours, please provide your ID # CE/CPE Hours Done