..:: Learning Stream ::..

All questions marked by an asterisk are required

Event Name:

Needs Assessment/Continuing Ed Request Form

*First Name:

*Last Name:

*Email Address:

*Retype Email Address:

*Phone Number:

*What is your role?

*Please specify:

*What education or additional training do you need to improve your job performance? Be specific such as 'I need to know more about...' or 'I need to know how to...' (need more specific information than 'need CE hours'):

*Please provide any other information or specific details that would help describe your need.:

*Please indicate your area:

Inpatient Units (Medical; Medical-Surgical; Short Stay; Progressive Care; Oncology; Critical Care; Cardiac; Labor & Delivery; NICU; Mother/Baby/Lactation/WH-GYN; Ortho/Neuro; Rehab; ACE)
Outpatient or Specialty Departments (Emergency; OR/Preop/PACU/GI Lab/Surgery Support; Diagnostics/MRI/CT/Nuclear Med/ Cath Lab; Cardiopulmonary Rehab; Home Health/Hospice/Home Infusion; Hospital Based Clinic; Physicians Clinic; Diabetes Institute)
Centralized Function (Administration; Care Management / Utilization Review; Infection Prevention; IV Team; Informatics; Palliative Care; Performance Improvement; Wound Care; Pre Surgery RNs/Surgery Scheduling; Learning Center; Employee Health; )
Allied Health Professions (PT/PTA; OT/OTA; SLP; Respiratory Care; Radiologic Technology; Sonography; Social Work; Mental Health Practitioners; Surgical Technology; Medical Assisting; Phlebotomy; Medical Laboratory Science)
Nebraska Methodist College (Nursing Division; Health Professions Division; Professional Development Division; Arts & Sciences Division)
Other (please specify)

Please specify:

*Please check the box next to any topic below that you feel is an area of educational need for your professional practice.:

*Why is this education needed? (choose all that apply):

Performance improvement issue or high risk potential
Knowledge needed (new research findings/evidence based practices, new trends, new procedure)
Have some knowledge but need skills training (new procedures, difficulty with current skills required)
Other

*Tentative/Ideal Date and Time/Time of Year:

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Save Information:

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