Lecture Request Form - Self-Insurance Programs_ Self-Insurance Programs

Requestor Information

Name *

First

Last

Title

University/Organization

Department/Service *

Email Address *

Phone Number

Event Details

Lecture Topic *

Type of Event *

Examples: Department Meeting, New Resident Orientation, Quarterly Executive Meeting

Estimated Number of Attendees *

Audience Description *

As best as possible, please describe who will be in attendance by status (e.g., attendings, residents, students), license type, and specialty. This information will help with the presentation build.

Total Amount of Lecture Time *

Date / Time of Event *

Date

Time

Please try to allow for at least 30 days advance notice.

Are you applying for CME credits for this educational activity? *

YES
NO

UF Health Providers: If you would like CME credits for the lecture, please contact the UF Continuing Medical Education program or apply at the following link: https://cme.ufl.edu/apply/. NOTE: The SIP does not apply, nor is responsible, for CME credits related to our lectures. This effort must be handled by the requesting service.

Address of Event (if attendance will be online, please indicate such in comments)

Address Line 1

Address Line 2

City

State

Zip Code

Comments