Number of Learners



Activity Title: FORMTEXT ?????Activity Date(s): FORMTEXT ?????Requesting Company/ Department: FORMTEXT ?????This form is for the organizing department to submit annual information to the CPD Department for all activities in a series.Number of LearnersThe TOTAL NUMBER of ATTENDEES must be reported, not just physician learners. Please designate the number of ‘Physician’ learners and ‘Other’ learners:PhysiciansOthersJanuaryAll Audience Learners FORMTEXT ????? FORMTEXT ????? FebruaryAll Audience Learners FORMTEXT ????? FORMTEXT ?????MarchAll Audience Learners FORMTEXT ????? FORMTEXT ?????AprilAll Audience Learners FORMTEXT ????? FORMTEXT ?????MayAll Audience Learners FORMTEXT ????? FORMTEXT ?????JuneAll Audience Learners FORMTEXT ????? FORMTEXT ?????JulyAll Audience Learners FORMTEXT ????? FORMTEXT ?????AugustAll Audience Learners FORMTEXT ????? FORMTEXT ?????SeptAll Audience Learners FORMTEXT ????? FORMTEXT ?????OctAll Audience Learners FORMTEXT ????? FORMTEXT ?????NovAll Audience Learners FORMTEXT ????? FORMTEXT ?????DecAll Audience Learners FORMTEXT ????? FORMTEXT ?????TOTAL LEARNERS FORMTEXT =Learner1+FebPhy+MarPhy+AprPhy+MayPhy+JunPhy+JulPhy+AugPhy+SepPhy+OctPhy+NovPhy+DecPhy !Undefined Bookmark, FEBPHY0 FORMTEXT =Learner2+FebOther+MarOther+AprOther+MayOther+JunOther+JulOther+AugOther+SepOther+OctOther+NovOther+DecOther !Undefined Bookmark, APROTHER0Registration IncomeIf registration fees were collected, enter the total amount received below. If fees were collected in a system outside of the Cloud portal, registration data must be attached behind this page.Registration Income$ FORMTEXT ?????Income from Other Sources (Foundation)This is an annual, cumulative number for each source:All income must be reported. If the activity received funds from other sources than those listed, provide the information below. FORMTEXT Enter Other Source$ FORMTEXT ????? FORMTEXT Enter Other Source$ FORMTEXT ????? FORMTEXT Enter Other Source$ FORMTEXT ????? FORMTEXT Enter Other Source$ FORMTEXT ?????Other Sources Income$ FORMTEXT =Other01+Other02+Other03+Other04 00.00Exhibitor Income (2000)To offer or expose to view; to exhibit the latest model of an object.This is an annual, cumulative total for each Exhibitor: (i.e., if Merck comes every month, have one line item with a total of the fees collected) List all Exhibitors that displayed materials for this activity and the amount paid. A copy of the signed agreement and check received must be attached behind this page.Exhibitor Organization(s):Amount Paid: FORMTEXT Enter Exhibitor Name Here$ FORMTEXT ????? FORMTEXT Enter Exhibitor Name Here$ FORMTEXT ????? FORMTEXT Enter Exhibitor Name Here$ FORMTEXT ????? FORMTEXT Enter Exhibitor Name Here$ FORMTEXT ????? FORMTEXT Enter Exhibitor Name Here$ FORMTEXT ????? FORMTEXT Enter Exhibitor Name Here$ FORMTEXT ????? FORMTEXT Enter Exhibitor Name Here$ FORMTEXT ????? FORMTEXT Enter Exhibitor Name Here$ FORMTEXT ????? FORMTEXT Enter Exhibitor Name Here$ FORMTEXT ????? FORMTEXT Enter Exhibitor Name Here$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Total Exhibitor Income$ FORMTEXT =Exhibitor01+Exhibitor02+Exhibitor03+Exhibitor04+Exhibitor05+Exhibitor06+Exhibitor07+Exhibitor08+Exhibitor09+Exhibitor10+Exhibitor11+Exhibitor12+Exhibitor13+Exhibitor14+Exhibitor15 00.00If necessary, continue the list of supporting organizations on an additional pageGrant Income (Commercial Support) (3000)If a grant was provided you must designate Restricted or Unrestricted, this will be on the contract.This is an annual, cumulative total for each Commercial Supporter: (i.e., if Merck comes every month, have one line item with a total of the fees collected)List all organizations that provided grants for this activity. Designate whether they were Restricted or Unrestriced and the amount given. A copy of the signed contract and check received must be attached behind this page. Agreements must have both signatures – one from the grantor and one from AdventHealth anization(s) that provided Grants:Amount of Grant: FORMTEXT Enter Grantor Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Grantor Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Grantor Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Grantor Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Grantor Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Grantor Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Grantor Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Grantor Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Grantor Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Grantor Name HereChoose an item.$ FORMTEXT ????? FORMTEXT ?????Choose an item.$ FORMTEXT ????? FORMTEXT ?????Choose an item.$ FORMTEXT ????? FORMTEXT ?????Choose an item.$ FORMTEXT ????? FORMTEXT ?????Choose an item.$ FORMTEXT ????? FORMTEXT ?????Choose an item.$ FORMTEXT ?????Total Grant Income$ FORMTEXT =Grant01+Grant02+Grant03+Grant04+Grant05+Grant06+Grant07+Grant08+Grant09+Grant10+Grant11+Grant12+Grant13+Grant14+Grant15 00.00If necessary, continue the list of supporting organizations on an additional pageIn-Kind Support (3001)A company (commercial interest) that loans equipment, space, disposable supplies (needles, masks, gloves, etc.) animal parts/tissue, cadavers, etc.This is an annual, cumulative total for each Supporter: (i.e., if Merck comes every month, have one line item with a total of the fees collected)List all organizations that provided items for this activity. Designate whether the items were durable equipment, disposable supplies, animal or human tissue. Items provided must be listed on the contract including their value. A copy of the signed contract and check received must be attached behind this page.Supporting Organization(s):Amount of Support: FORMTEXT Enter Supporter Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Supporter Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Supporter Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Supporter Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Supporter Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Supporter Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Supporter Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Supporter Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Supporter Name HereChoose an item.$ FORMTEXT ????? FORMTEXT Enter Supporter Name HereChoose an item.$ FORMTEXT ????? FORMTEXT ?????Choose an item.$ FORMTEXT ????? FORMTEXT ?????Choose an item.$ FORMTEXT ????? FORMTEXT ?????Choose an item.$ FORMTEXT ????? FORMTEXT ?????Choose an item.$ FORMTEXT ????? FORMTEXT ?????Choose an item.$ FORMTEXT ?????Total Support Income$ FORMTEXT =Support01+Support02+Support03+Support04+Support05+Support06+Support07+Support08+Support09+Support10+Support11+Support12+Support13+Support14+Support15 00.00If necessary, continue the list of supporting organizations on an additional pageSpeaker ExpensesPaying speakers an honorarium FORMTEXT Enter Speaker NameHonoraria$ FORMTEXT ????? FORMTEXT Enter Speaker NameHonoraria$ FORMTEXT ????? FORMTEXT Enter Speaker NameHonoraria$ FORMTEXT ????? FORMTEXT Enter Speaker NameHonoraria$ FORMTEXT ????? FORMTEXT Enter Speaker NameHonoraria$ FORMTEXT ????? FORMTEXT Enter Speaker NameHonoraria$ FORMTEXT ????? FORMTEXT Enter Speaker NameHonoraria$ FORMTEXT ????? FORMTEXT Enter Speaker NameHonoraria$ FORMTEXT ????? FORMTEXT Enter Speaker NameHonoraria$ FORMTEXT ????? FORMTEXT Enter Speaker NameHonoraria$ FORMTEXT ????? FORMTEXT ?????Honoraria$ FORMTEXT ????? FORMTEXT ?????Honoraria$ FORMTEXT ????? FORMTEXT ?????Honoraria$ FORMTEXT ????? FORMTEXT ?????Honoraria$ FORMTEXT ????? FORMTEXT ?????Honoraria$ FORMTEXT ????? FORMTEXT ?????Honoraria$ FORMTEXT ????? FORMTEXT ?????Honoraria$ FORMTEXT ????? FORMTEXT ?????Honoraria$ FORMTEXT ????? FORMTEXT ?????Honoraria$ FORMTEXT ????? FORMTEXT ?????Honoraria$ FORMTEXT ?????Honoraria Total $ FORMTEXT =Honor01+Honor02+Honor03+Honor04+Honor05+Honor06+Honor07+Honor08+Honor09+Honor10+Honor11+Honor12+Honor13+Honor14+Honor15+Honor16+Honor17+Honor18+Honor19+Honor20 00.00If necessary, continue the list of Speaker Expenses on an additional page.All Other ExpensesREMEMBER: These are annual, cumulative totals for the yearIncomeAmount:1000 Registration Fees (page 1)$ FORMTEXT =Reg 00.001002Optional Social Fees$ FORMTEXT 0.002000Exhibitor Income (total, page 2)$ FORMTEXT =Exhibitor01+Exhibitor02+Exhibitor03+Exhibitor04+Exhibitor05+Exhibitor06+Exhibitor07+Exhibitor08+Exhibitor09+Exhibitor10+Exhibitor11+Exhibitor12+Exhibitor13+Exhibitor14+Exhibitor15 00.003000Grants/ Commercial Support (total, page 3)$ FORMTEXT =Grant01+Grant02+Grant03+Grant04+Grant05+Grant06+Grant07+Grant08+Grant09+Grant10+Grant11+Grant12+Grant13+Grant14+Grant15 00.003001In-Kind Support (total, page 4)$ FORMTEXT =Support01+Support02+Support03+Support04+Support05+Support06+Support07+Support08+Support09+Support10+Support11+Support12+Support13+Support14+Support15 00.003002Other Source Income (page 1)$ FORMTEXT =Other01+Other02+Other03+Other04 00.00Expenses4000Speaker Honoraria (total honoraria, page 5)$ FORMTEXT =Honor01+Honor02+Honor03+Honor04+Honor05+Honor06+Honor07+Honor08+Honor09+Honor10+Honor11+Honor12+Honor13+Honor14+Honor15+Honor16+Honor17+Honor18+Honor19+Honor20 00.005000Catering (all food expenses)$ FORMTEXT ?????6000Printing, Supplies, and Equipment (AV rental, badges, posters, etc.)$ FORMTEXT ?????6001Postage$ FORMTEXT ?????7000Miscellaneous (All other expenses, copies of receipts must be attached)$ FORMTEXT ?????7001CPD Services Rendered for CME approval$ FORMTEXT ?????center426085Copies of invoices and checks must be attached585000Copies of invoices and checks must be attachedTOTAL ACTIVITY COST $ FORMTEXT ?????Signature: Date: ______________________Title: ___________________________________________________ ................
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