Telephone Conference Site Response Form

	Title X
	Program Guidelines for Clinic Services March 11, 2008 12 – 1pm Central Daylight Saving Time 1 – 2pm Eastern Daylight Saving Time Complete one form for each registered site (not each participant) after the September 5th presentation SITE COORDINATOR First Name: Last Name: Agency: City: State: Zip: Please rate (check your response):   POOR EXCELLENT   SPEAKER   CONTENT   HANDOUTS                 Total # participating from your site (whether from home or office): Did your staff encounter any barriers to participating in this program? If yes, please explain: Suggestions for future telephone conferences: Additional Comments:

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316 N. Milwaukee St.
Suite 440
Milwaukee, WI 53202
414.224.5270
414.224.5265FAX