Registration Form

First Name:*

Middle Name:

Last Name:*

Title/Position:*

Birth Month and Day (MM/DD):*

Individual NPI (The number you use to identify yourself for healthcare transactions):*

Degree:*

License Type:*

MD DO NP PA CNM Other (Specify)

Other:*

License Number:*

License Exp Date (MM/DD/YYYY)*

Daytime or Work Phone:*

E-mail:*

Please Create a Password:

Please confirm your password:

1. Are you a Medi-Cal provider?*

Yes No

2. Are you a Family PACT provider?*

Yes No Application in progress

3a. Site Name:*

3b. Business/Site NPI (this is the number used to identify your work site):*

3c. Site Address:*

3d. City:*

3e. State:*

3f. Zip code:*

3g. Site Phone Number:*

3h. Site Alternative Phone Number:

3i. Site Email:*

4. Your Primary Profession/Discipline:*

5. Your Primary Functional Role:*

6. Type of Entity/Practice Type (Select one):*

College/University Rural Health Center Community Health Center (e.g. Federally Qualified Health Center) Other Non-profit Health Center Mobile or Intermittent Clinic Hospital/Hospital-affiliated Clinic Military Health System/Veterans Health Admin. facility Private Practice (Solo/Group) County/Local Health Department Other (Specify):

Other:*

7. Primary Employment Setting:*

Rural Suburban/urban

8. Which training date(s) are you registering for?*

9. Have you completed an IUD training before?*

Yes No

10. Approximately how many IUDs have you placed in the last 12 months?*

11. IUD Hands-On Skills Lab (optional but highly recommended): The IUD Hands-On Skills Lab on April 10 is an optional 40-minute practice session focused on difficult IUD placement and removal, led by expert medical educators. Pelvic models and computer simulators will be available. Please bring your IUD demo kits from the training event. The Hands-On Skills Lab session is not eligible for CME credits.

Eligibility Requirement:
This is open to all providers who would like additional hands-on practice to build their skills and confidence. We strongly encourage providers to sign up for the IUD Hands-On Skills Lab to get the most out of this training. Select your option.*

12. Nexplanon Skills Review (optional): This is a 15-minute Q&A review of implant insertion and removal techniques, led by an Organon Representative. Demo kits will be available for practice. It is available on Friday, April 10 from 9:00 a.m. - 12:00 p.m. PST. You can drop in at any time and ask questions. The Nexplanon Skills Review is not eligible for CME credits.

Eligibility Requirement:
The Nexplanon Skills Review is limited to ACTIVE Nexplanon-Trained Healthcare Providers who register for April 9 - IUD Training only. To qualify, you must have already completed a Nexplanon Placement Training, the 2018 re-training, and have inserted or removed Nexplanon in the past 3 years. Providers registering for the April 10 - Implant Training or both April 9-10 - IUD and Implant Training are not eligible for the Nexplanon Skills Review Select your option.*

9. Have you completed an IUD training before?*

Yes No

10. Approximately how many IUDs have you placed in the last 12 months?*

11. IUD Hands-On Skills Lab (optional but highly recommended): The IUD Hands-On Skills Lab on April 10 is an optional 40-minute practice session focused on difficult IUD placement and removal, led by expert medical educators. Pelvic models and computer simulators will be available. Please bring your IUD demo kits from the training event. The Hands-On Skills Lab session is not eligible for CME credits.

Eligibility Requirement:
This is open to all providers who would like additional hands-on practice to build their skills and confidence. We strongly encourage providers to sign up for the IUD Hands-On Skills Lab to get the most out of this training. Select your option.*

Nexplanon Clinical Training Program (CTP) Questions

N1. Have you completed a Nexplanon Clinical Training Program (CTP) before?*

N1a. Enter your Nexplanon training certificate number.*

N2. Have you completed the 2018 Nexplanon Re-Training?*

Yes No Not Sure

N3. Which of the following best describes your current Nexplanon provider training status regarding the Nexplanon Clinical Training Program (CTP)?

- ACTIVE: I HAVE completed the CTP and HAVE inserted/removed Nexplanon in the past 3 years.
- INACTIVE: I HAVE completed the CTP but HAVE NOT inserted/removed Nexplanon in the past 3 years.
- NEW: I HAVE NEVER completed the CTP.*

ATTENTION: You will receive an email from Veronica Espinoza (Veronica.Espinoza@ucsf.edu), to confirm your attendance and secure your spot.

Comprehensive IUD and Contraceptive Implant Training

Sacramento, CA