PHPCB
CONTINUING EDUCATION CONTACT HOURS

(Requirement: 90 contact hours every three years. Contact hour is defined as 60 minutes of attendance.)

NAME:___________________________________________________________________

CERTIFICATION NUMBER:____________________________________________________

Title of Continuing Education Program or Conference
Sponsor(s)
Date(s)
Total Number of Contact Hours

 

 

 

     

 

 

 

     

 

 

 

     

 

 

 

     

 

 

 

     

 

 

 

     
The total number of contact hours listed herein is being submitted to the Illinois Public Health Administrator Certification Board in conformance with its requirements for re-certification. I attest that the information described above true is true and correct to the best of my knowledge.

SIGNATURE:______________________________________

DATE:___________________________________________

Please mail to:

PHPCB
Attn: Vikki Wiebel
UIC SPH (MC 923)
1603 West Taylor Street
Chicago, IL 60612

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