OTHER FORM 

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OTHER FORM

Purpose: To provide a process for CAP participants to receive  starred activity credit for a project, collaboration, consultation, coordination, or effort of such caliber/quality that is not represented by other  starred activities described in the Activities Check list. This endeavor requires completion of the following information and the participant’s manager’s signature for the activity to qualify.

Category:

____ Clinical Practice/Expertise ____Leadership/Facilitation

____Teaching ____Outcomes/EBM

____Advocacy

ACTIVITY DESCRIPTION: ______ _________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Justification: Explain succinctly why this endeavor merits an elevated status  within the CAP

Activities._____________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

_________________________________________________________________________________

Participant must include “evidence” of activity: brochure, photo, etc

Participant’s Signature Date

Manager’s Signature Date

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