Olson Center Video Nursing Education Registration Form

Please print out this form, complete, and send it in with each completed video evaluation form.

Name ________________________________  RN/LPN License # ___________

Address ______________________________________________

City ____________________  State _______________  Zip Code _____________

Phone __________________________  Fax  __________________________

e-mail _______________________________________________

Title of Video Viewed ____________________________________________

Date you viewed the video _________________________________________

Time of day you viewed the video  ___________________________________

Please answer the following questions by circling the answer:

Additional Comments:

______________________________________________________________________________

______________________________________________________________________________ ______________________________________________________________________________

Checklist for each video viewed:

• Complete a new registration form

• Complete the evaluation form for the specific video

• Make $10 check or money order payable to "University of Nebraska Medical Center

• Send to

UNMC Olson Center for Women's Health

983255 Nebraska Medical Center

Omaha, NE  68198-3255

Attn:  Lana

Your nursing certificate for 1.0 contact hour will be mailed to you within 3-4 weeks.

Date last updated: Jan. 11, 2005
ljmolczy@unmc.edu