Info AHEC RCP Course Request Form Form Type AHEC RCP Course Request The "Form Type" field will default to the division offering the course you have selected. If you wish to request a course from another division, please return to the Allied Health Hot Topics Page, click on the name of that division, and follow the link for that division’s form. CASCE# Event # Date of Request Year -- 2013 2014 2015 2016 2017 2018 / Month -- January February March April May June July August September October November December / Day -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 AHEC Region Area L Charlotte Eastern Greensboro Mountain Northwest South East Southern Regional Wake Contact Person Phone Number E-Mail Address Target Audience Choose all the apply Audiologists Medical Technologists Nuclear Medicine Technologists Occupational Therapists Physical Therapists Radiologic Technologists Radiation Therapy Technologists Rehabilitation Counselors Speech Language Pathologists Ultrasonographers Other If other, please list Anticipated Number of Participants Minimum Number of Participants Required (if applicable) Maximum Number of Participants (if applicable) Objectives Please describe what you need this course to provide or accomplish. Location of Course Please provide full address, including zip code and suite/office/room number if applicable. Tentative Date and Time (First Choice) Year -- 2013 2014 2015 2016 2017 2018 / Month -- January February March April May June July August September October November December / Day -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Hour -- 12 01 02 03 04 05 06 07 08 09 10 11 : Minute -- 00 05 10 15 20 25 30 35 40 45 50 55 AM/PM -- AM PM Tentative Date and Time (Second Choice) Year -- 2013 2014 2015 2016 2017 2018 / Month -- January February March April May June July August September October November December / Day -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Hour -- 12 01 02 03 04 05 06 07 08 09 10 11 : Minute -- 00 05 10 15 20 25 30 35 40 45 50 55 AM/PM -- AM PM Tentative Date and Time (Third Choice) Year -- 2013 2014 2015 2016 2017 2018 / Month -- January February March April May June July August September October November December / Day -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Hour -- 12 01 02 03 04 05 06 07 08 09 10 11 : Minute -- 00 05 10 15 20 25 30 35 40 45 50 55 AM/PM -- AM PM Length of Course/Program in Hours Decide which presentation style you prefer (Live or Webinar) and choose one topic from that style’s drop down list. Leave the other set on "Not Selected." Live Presentation Not Selected Quality of Life Pre and Post Heart and Lung Transplant (Burker) Psychological Stress Associated with Heart and Lung Transplant (Burker) Psychological Factors in Cystic Fibrosis (Burker) Rehabilitation Counselor Training (Variable Speakers) Webinar Presentation Not Selected Quality of Life Pre and Post Heart and Lung Transplant (Burker) Psychological Stress Associated with Heart and Lung Transplant (Burker) Psychological Factors in Cystic Fibrosis (Burker) Rehabilitation Counselor Training (Variable Speakers) Would you be open to alternative presentation style for this topic? Yes No If yes, please indicate which style you would consider Live Teleconference Webinar Will lunch/dinner be provided for presenter? (for live presentation only) Yes No If Requested Transportation Contact If air travel will be necessary, please provide the name and phone number of the person who will pick up the speaker. Additional Comments or Considerations Please include any additional requests or information that will assist the AHEC coordinator in scheduling your course.