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CHT CE Verification Form

1. Name: *This question is required.

2. Hospital/Health System Where You Serve: *This question is required.

3. Mailing Address: *This question is required.

4. Organization Providing the Event: *This question is required.

5. Please provide event details include date, time and hour of CE earned: *This question is required.

	Name of Event
	Date of Event
	Time of Event
	CE Hours Earned

6. Please list the title and speakers for the session(s) you attended: *This question is required.

7. Please list at least two key education takeaways/learning objectives you gained from this event *This question is required.

Key Takeaway
Key Takeaway

8. Topics covered at this event (please select any that may apply): *This question is required.

9. Please initial and date the text boxes below. By initialing this form you acknowledge that the information provided is true and accurate. The continuing education hours specified above were attended in their entirety and may be applied to earning THT's Certified Healthcare Trustee designation. *This question is required.

Initials
Date

10. Please provide email(s) (please separate each email address by a comma) of whom to receive an email of submission after completing the form. *This question is required.