DATE: ___________________

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NAME (FIRST) (LAST) (TITLE—MD, RN, OTHER)

ARE YOU AFFILIATED WITH LGH? (CIRCLE ONE)  YES  NO

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 DEPARTMENT TELEPHONE

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OFFICE ADDRESS (IF APPLICABLE)

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CITY STATE ZIP

 REQUESTED TOPIC:_________________________________________________________

PLEASE WRITE REASON FOR REQUEST (ATTACH ANY SUPPORTING DOCUMENTATION, INCLUDE ALL NEEDS ASSESSMENT CONDUCTED):

OBJECTIVES YOU WOULD LIKE TO SEE ADDRESSED IN THIS TALK: (REQUIRED)

1.___________________________________________________________

2.___________________________________________________________

3.___________________________________________________________

4.___________________________________________________________

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