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Clinical Safety & Effectiveness Educational Program - Participant Information

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Please fill out the following form to express your interest in becoming a CS&E participant.

Your Information


CS&E Contact

If you have already contacted the CS&E Executive Team, please include the name of the person whom you contacted. Otherwise, you will be contacted to discuss your interest in the program.

Colleague Information

Can you suggest a colleague to attend the CS&E course with you?

Existing Projects

Team Information

You must have a team to support your project.
Teams require: physician, nurse, pharmacist, etc.

Team Member 1:


Team Member 2:


Team Member 3:


Additional Contact Information

Your Assistant:


Department Head/Chair:


Assistant to Department Head/Chair: