5-15-24 CEU form Name First Last Street Address* City* State* Zip* Phone*Email* Profession Type*Pharmacist/Pharmacy TechNurseAdministratorLicense Number*(FL Pharmacists: include PS number for general license only-do NOT include PU license number) For pharmacists/pharmacy techs*If you’d like us to report your CE to NABP, please include your NABP profile number. Date of Birth (MM/DD)*Please provide DOB in MM/DD format For Administrators*(FL Administrators: include your NH license number – NH1234) For Nurses*FL Nurses: include your RN/PN/LPN license number Did the speaker achieve the goals and objectives provided for this program?*YesNoThe speaker's presentation was free from bias*AgreeDisagreeHow much do you feel this presentation will impact your daily practice?*1 – not at all2 – somewhat3 – oftenOn a scale of 1 to 5, please rate today's webinar* 1 (Not great) 2 (Just OK) 3 (Decent) 4 (Good, not Great) 5 (Fantastic!) Additional commentsPlease share any additional information you’d like to share from your participation in this activity. Δ
