GoSignMeUp CE Course Request Form GoSignMeUp CE Course Request Form Requestor Name (first, last) * RequiredRequestor Email address (ex. JEDoe@uams.edu) * Required Phone number (###)###-#### * RequiredContact Info (if different from above)College (if applicable)College of Health ProfessionsCollege of MedicineCollege of NursingCollege of PharmacyCollege of Public HealthGraduate SchoolOtherDepartment * RequiredName of primary instructor for the course. * RequiredThis information appears on the course confirmation and course emails.Course numberAll courses that integrate with Blackboard have "GSMU_ " as a prefix, if using a new course shell. If the course already exists in Blackboard, enter the Blackboard course number. For a non-Blackboard course or event, leave it blank.Course name (example: Nitrous Oxide Sedation) * RequiredCourse description (appears in the online catalog) * RequiredCourse is (select one): * Required Classroom (face-to-face) Fully online in Blackboard (requires new course shell) Fully online in Blackboard (uses existing course shell) Fully online in non-Blackboard system Partially online Other Location for Classroom or Partially Online CoursesPartially Online DescriptionPlease briefly describe how the online/classroom sessions will work together. (Ex: Skills labs will take place on campus the last week in May. Students will be required to have all online coursework completed the previous week.) Course start date * Required MM slash DD slash YYYY Course end date * Required MM slash DD slash YYYY Course start time : Hours Minutes AM/PM AM PM AM/PM Course end time : Hours Minutes AM/PM AM PM AM/PM Type of credit hours * Required None CE hours CEUs Contact hours TAPP hours Nursing CE hours Number of credit hoursPlease enter a number less than or equal to 100.Full course fee per regular studentAre any special pricing, discounts, payment options needed? Payment is made by participant credit card. If an IDT is needed, please note below.Do you have additional comments or questions for the administrator?
