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Course Request Form
Live/Online Course Creation Request
Includes all fields necessary for HWapps to create a course for a client.
Course Details
Course Type
*
Online
Live
Your Name:
*
Your Email Address:
*
Course Name:
*
Course Description:
Use this space to provide a brief explanation of what the course entails. This is the description that will display in the Training Center.
Estimated Course Duration (in Hours):
*
Ex. 0.5, 1.0, 1.5, etc.
Number of Sessions:
*
1
2
3
4
5
Date - Session 1
Date Format: MM slash DD slash YYYY
Session 1 - Start Time
:
HH
MM
AM
PM
Session 1 - End Time
:
HH
MM
AM
PM
Date - Session 2
Date Format: MM slash DD slash YYYY
Session 2 - Start Time
:
HH
MM
AM
PM
Session 2 - End Time
:
HH
MM
AM
PM
Date - Session 3
Date Format: MM slash DD slash YYYY
Session 3 - Start Time
:
HH
MM
AM
PM
Session 3 - End Time
:
HH
MM
AM
PM
Date - Session 4
Date Format: MM slash DD slash YYYY
Session 4 - Start Time
:
HH
MM
AM
PM
Session 4 - End Time
:
HH
MM
AM
PM
Date - Session 5
Date Format: MM slash DD slash YYYY
Session 5 - Start Time
:
HH
MM
AM
PM
Session 5 - End Time
:
HH
MM
AM
PM
Attend all dates required?
Yes
No
Accreditation
*
None
ACPE
AMA PRA 1
CE
Certificate
CME
Upload Certificate:
Other Information for Participants:
Use this space to add additional instructions for course participants. (Required materials/equipment, further instructions, DSRIP info, etc.)
DSRIP Details
PPS Name
*
Select all POs?
*
Yes
No, select individual
Select POs by Partner Type:
Acute Care
Behavioral Health
Developmental Disability Organizations
Home Health Agencies
Obstetrics
Pediatrics
Primary Care
Skilled Nursing Facilities
All Other
OR by Facility Type:
Article 16 Clinics (OPWDD)
Article 28 Diagnostic & Treatment Centers
Home Care Agency
Hospital Article 28 Outpatient Clinics
Inpatient
Non-licensed CBO
Nursing Home/SNF
Outpatient Behavioral Health (Art 31 & 32)
Private Provider Practice
OR list individual POs:
Course Content
Describe your course here, and/or post any links:
Upload Content Here:
Upload Content Here:
Upload Content Here:
Quiz Details & Content
Does the course need an attestation statement?
*
Yes
No
Please indicate what you want the attestation statement to say. If this is left blank, we will draft an attestation statement for you.
Does the course require any other quiz questions?
*
Yes
No
Please list any additional questions, followed by the answers (both correct and incorrect) :
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