A.G. Holley State Hospital
Topic:"Florida Tuberculosis 2002 – A Vision into the Future"
"Public Health in the Control of Infectious Disease"
Date: Wednesday, April 10, 2002
Place: Auditorium, A.G. Holley State Hospital, 1199 W. Lantana Road, Lantana, Fl.
Time: 10:00 a.m. – 12:00 p.m. (EST)
Objectives: By the completion of the presentation, participants will be able to:
Lunch: Provided- 12:00 p.m. (Reservation must be made by April 4, 2002)
Sponsors: Florida AHEC Network and Everglades Area Health Education Center, Inc.
Program also supported by: A. G. Holley State Hospital, American Lung Association of Florida, Inc., Florida Bureaus of TB and Refugee Health and Laboratories
Registration:By phone: (561)540-3364 SC: 256-3364 fax: (561) 540-3366 or SC: 256-3366
Email:Affette_McIntosh@doh.state.fl.us the registration form- only required if attending in person.
TB Training Registration Form
(Please fax to Affette (Melody) McIntosh
A.G. Holley State Hospital at (561) 540-3366
Problems/Questions-call (561) 540-3364Please Print Neatly
Phone ( )_______________ SC ( )___________ Fax ( )____________
City______________________________ State_______ ZIP ___________
SSN#______________________ (required of non-Dept. of Health employees)
License Type: ______________ License #: _________________
Organization/Office: (Check one)
County / State Health Dept. Hospital HMO
Private Medical Office Nursing Home, Correctional Facility
Individual Other, specify____________________________
Position: (Check one)
MD/DO PA/ARNP RN LPN
Health/Family Service Rep. Administrative Staff Support Staff
Computer/Data Staff Educator Lab Staff
Respiratory Care Staff Nutrition Staff Pharmacy Staff
Education Level: (Check highest level attained)
High School Associate Bachelors
Masters Doctorate Post Doctorate
Business/Technical/Vocational Other, specify_______________________
Training Registration: Please specify
Comprehensive Clinical TB Course _________________________________________
Quarterly Grand Rounds _ April 10, 2002 A. G. Holley Hospital - Lantana
TB Skin Testing-Train-the-Trainer ________________________________________
TB Skin Testing-Certification Class ________________________________________
Collaborative Case Conference ________________________________________
Satellite Teleconference ________________________________________
Other, specify_________________ ________________________________________
Please visit our web site at http://www.doh.state.fl.us and choose Tuberculosis, Training Opportunities for course descriptions, dates and locations
Note: We are working on an on-line registration form for future programs.