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Application Namegov-hlth Form Nameema-3735 Form TitleRequest for Adjudication Form DescriptionEMAs in shortfall for continuing competence requirements should complete this form to request adjudication. Please make sure that you submit your supporting documentation along with the form. { "inline" : true, "hidden_input" : false, "language" : "en", "statusbar" : false, "menubar" : false, "plugins" : "lists link", "toolbar" : "bold italic | bullist numlist outdent indent | link", "browser_spellcheck" : true, "encoding" : "xml", "entity_encoding" : "raw", "forced_root_block" : "div", "visual_table_class" : "fr-tinymce-table", "skin" : false, "convert_urls" : false, "content_css" : "default" }

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Outline the details of the course content and what skills and/or knowledge were obtained from the continuing education activity submitted for adjudication below.

Include the course provider, name of activity, date, duration, location, and certificate of completion.
If submitting a conference, include a copy of the agenda with the breakdown of sessions and their content, and your verification of attendance.
For patient contacts, please provide the date, location, your role, patient chief complaint or type of contact, and the skills performed for the patient for each contact submitted.

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Attach all of your supporting documentation

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HLTH 3735 Rev. 2023/01/18

Current Date

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Request for Adjudication

Licensee Information

Summary of Adjudication Request

Attach Your Supporting Documentation