*Contact Person's Name
*Required information
Title
Department
*Organization
*Street Address
(Site Location)
*City
*State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*Zip
-
*County
*Phone
*Email
*Email (confirm)
*3 AVAILABLE DATES:
First
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date
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
Year
2007
2008
Second
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date
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
Year
2007
2008
Third
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date
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
Year
2007
2008
*Access to laptop computer?
Yes
No
*Access to an LCD projector?
Yes
No
*Number of participants (est.)
Please select one of the 5 EPIC SCAN Programs below:
1. SCAN Primary Care Providers
2. SCAN EXPRESS Primary Care Providers
3. SCAN School Nurses
4. SCAN Hospital Staff
5. SCAN Emergency Medical Service Providers
Click Submit button only once.
