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Training Activity Request & Planning

A. ADMINISTRATIVE INFORMATION

Training Coordinator (liaison person)
Salutation *
Name *
Email *
Phone *
Fax
Dept & Division *
Organisation *
Address 1
Address 2
Postal Code
Country *
 

B. TRAINING ACTIVITY INFORMATION 

Title of Activity
Name of Unit or Entity Sponsoring Activity
Proposed Date(s) of Training
Proposed Time(s) of Training
Proposed Training Location (i.e. at your site or at IMH/CMHE)
List Specific Training Goals and Anticipated Outcomes
 
Areas of Interest in Mental Health Education
Disciplines
(tick all that apply)
 If others, please specify
 
Sub-specialists
(tick all that apply)
 If others, please specify
 
Competencies
(tick all that apply)
 If others, please specify
 
Training Format &/or Components (check all components that apply & best describes our request)
Duration: No. of hours
 
Duration: No. of hours 
or No. of Days
Duration: No. of hours
or No. of Days 
Duration: No. of hours
No. of Days
Duration: No. of hours
No. of Days 
 
Other Requests &/or Comments
* Denotes Mandatory  
 
A member of National Healthcare GroupWork Life Activeness AwardTUVTUV   Comm Chest Award 2012