2024 Colposcopy & HPV Refresher & Update CourseIHS/Tribal/Urban

2024 Colposcopy & HPV Refresher & Update Course

IHS/Tribal/Urban

March 12, 2024

Sheraton Uptown Hotel in Albuquerque, NM.

Please plan on completing the form in its entirety. This site cannot save your information for completion at a later date.

Prior to Starting this Form: Complete your UNM Tuition Remission paperwork (remember proper signatures are REQUIRED), complete your UNM PR and make a copy of your check, you will be required to upload a copy of these documents at the end of this form.

Registration

Please indicate if you will attend the Refresher course In-person or virtually.*

Providers from IHS, Tribal or Urban Clinics can attend either course for free.

In-Person

Virtual

Contact Information

First Name*

Last Name*

What is your preferred name to emphasize on your badge?

First Name, Nickname, etc... (e.g. Gary, Dr. Smith)

Credentials (i.e. MD, RN, PA, etc.)*

Provide all of your credentials. If medical student, list Medical Student.

Specialty*

Select or enter value

If OTHER, please provide Specialty

Professional Job Title*

Organization*

(i.e. agency, service unit/tribal, hospital)

Please select the organization you work for:*

IHS

Tribal

Urban Clinic

I don't work for IHS, Tribal or an Urban Clinic

Street Address*

City*

State*

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Zip*

Is this your home or business address?*

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Phone Number*

Phone Number Type*

Home

Work

Cell

Cell Phone Number*

This will ONLY be used on event days.

Email*

Other Information

What CME credit type do you need?*

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How did you hear of this activity?*

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Other

Do you have previous colposcopy training/experience?*

Yes

If yes, where did you learn colposcopy?*

IHS course

ASCCP course

Other

If other, please list.

How many years have you been practicing colposcopy?*

If you learned colposcopy through IHS or ASCCP, are you finished with your mentorship?

Yes

If yes, when did you finish?*

If no, how many supervised colposcopies have you finished?*

If you learned colposcopy through a non-IHS program, did your training include a period of hands-on supervision with a teacher or mentor?*

Yes

Registration Code: Onsite Rate*

Please select your registration category.

Providers from IHS, Tribal or Urban Clinics can attend In-Person or Virtually for free.

Select or enter value

Payment

Payment Method*

Please select your payment method below. If you are using another payment option (Free registration, Scholarship, etc...) please select other and explain.

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Please note, once you submit, you will automatically be redirected to our payment portal.

Payment is NOT required.

Please make sure you EXIT the Touchnet page so your registration enters our system.

Your registration form is complete once you click the submit button below.

You have selected to pay using a Check, PR or Other

If this is incorrect, please change your Registration Code above.

Once you have submitted this form you will be automatically directed to our TouchNet payment portal.

Please make sure you EXIT the Touchnet page so your registration enters our system.

Your registration form is complete once you click the submit button below.

*Your conference registration is not complete until we have received your payment method.

If you selected other payment method please explain*

You have selected to pay using a Credit Card

If this is incorrect, please change your Registration Code above.

Once you have submitted this form you will be automatically directed to our TouchNet payment portal.

If you are paying with a credit card you MUST complete your payment in this portal.

*Your conference registration is not complete until we have received your payment method.

Please choose your credit card type*

Once you have submitted this form you will be automatically directed to our TouchNet payment portal. Please enter your payment information to complete your registration. If you do not complete the payment page your conference registration is incomplete. You will receive an email from TouchNet with your payment receipt once payment is received.

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You have selected UNM Tuition Remission, in the registration Code above

The Tuition Remission Program is extended to: Regular full/part-time staff, faculty (from their initial date of hire) and UNM Retirees

If this is incorrect, please change your Registration Code above.

Tuition Remission

Professional Development

Course: 2024 Colposcopy Course

Class Day/Time: March 12, 2024

Cost:

Early Bird (Until 2/19/24)

Providers from IHS/Tribal/Urban Indian Clinics: $0.00

Providers from NON_IHS/Tribal/Urban Clinics: $300.00

Virtual Providers from NON-IHS/Tribal/Urban Clinics: $250.00

UNM Residents/Fellows: $40.00

Regular Rate (2/20/24-3/6/24)

Providers from IHS/Tribal/Urban Indian Clinics: $0.00

Providers from NON_IHS/Tribal/Urban Clinics: $340.00

Virtual Providers from NON-IHS/Tribal/Urban Clinics: $290.00

UNM Residents/Fellows: $40.00

Onsite Rate (3/7/24-3/12/24)

Providers from IHS/Tribal/Urban Indian Clinics: $0.00

Providers from NON_IHS/Tribal/Urban Clinics: $365.00

Virtual Providers from NON-IHS/Tribal/Urban Clinics: $315.00

UNM Residents/Fellows: $40.00

Information regarding Tuition Rates and the Taxability of Tuition Remission my be viewed at: http://bursar.unm.edu/index.html

Supervisor Approval*

Supervisory approval is required if any of the following apply:

A credit course taken during the employee's regular work schedule (approval is to authorize the absence from work and to approve an alternative work schedule): or
A non-credit professional development course taken during the employee's work schedule that is related to the employee's job or a UNM job to which the employee may reasonable aspire (approval is to authorize absence from work and approve an alternative work schedule): or
A non- credit health and fitness course taken during the employee's work schedule (approval is to authorize the absence from work and to approve an alternative work schedule).

Select

How will you submit your Tuition Remission Form?*

I will upload my form now with the appropriate signatures required.

I will email CPL at HSC-CPL@salud.unm.edu, my completed Tuition Remission form.

What is your UNM Banner ID?*

TR Employment Status*

Faculty/Staff

Retiree

TR Work Number*

Phone

Employee Certification

Please check the following statements, to indicate you acknowledge each.

Information regarding Tuition Rates and the Taxability of Tuition Remission my be viewed at: http://bursar.unm.edu/index.html

I acknowledge that I have reviewed UAP 3700, “Education Benefits” and certify this request for Tuition Remission Benefit is within the maximum allowable benefit per semester as provided in the Policy.*

I understand that I am responsible to repay all costs that exceed the maximum allowable benefit.*

I acknowledge the University will bill me for any excess tuition costs that have been paid. If the bill is not paid, UNM may collect any excess through payroll deductions*

I acknowledge that the amount of tuition benefits for certain courses are considered taxable under current published IRS regulations. I understand that any taxable tuition benefit I receive will be added to my wages as taxable income and will be subject to income tax withholding.*

Additionally, I understand that if the amount of tuition benefits I receive during the calendar year exceeds the published IRS maximum amount, the amount in excess of the IRS maximum will be added to my wages as taxable income and will be subject to income tax withholding.*

Signature*

By electronically signing this document, I agree the following information I provided above is complete and accurate.

TR Date

Please note, once you submit, you will automatically be redirected to our payment portal.

Please make sure to EXIT the Touchnet page so your registration enters our system.

File Upload*

*Your conference registration is not complete until we have received your payment method.

If you are paying by check, a copy of the check MUST be uploaded here. Checks MUST be received by UNM CPL within 5 business days of completing this registration site. Please make checks payable to: UNM CPL 1 University of New Mexico MSC09 5370 Albuquerque, NM 87131-0001

If you are paying by UNM PR, a copy of the PR MUST be uploaded here.

If you are a Student please upload your current fulltime student schedule here.

Upload your signed Tuition Remission Form here.

*This is a required field and you will not be able to finish this form unless you upload something.

If you are unable to upload the necessary information listed above please contact us at HSC-CPL@salud.unm.edu or 505-272-5166 for assistance.

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