Please complete form as accurately and completely as possible and retain for your records.	
Webinar Title	     	
Date & Time	     	
Associated URL	     	
Hosting organization	     	
Names and Credentials of Presenters	     	
Webinar Goals & Objectives	     	
Contact hours Specify actual hours of engagement. Attach documentation if possible.	     	
Participant role	Check all that apply:
  Listening to presenters to acquire new information/knowledge
  Exploration of relevance and potential applications of workshop content to local situation 
  Interactive dialogue and questions with presenters and/or colleagues
  Participate in individual and group activities 
  Other – please specify       

My signature below attests to my participation in the WEBINAR described on this document. 
				
Participant Name (Print) 			Signature
				
			Date